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SPRING 2001 




Physicians provide 
the underserved with, 
care and compassion 







A pharmacist 
working in the 
apothecary shop 
at Children's 
Hospital in Boston 




Letters 3 

Pulse 5 

A groundbreaking for a new HMS build- 
ing; HMS accolades; die Second Year Show 

President's Report 8 

by Charles]. Hatcm 

Bookmark 9 

A review by Elissa Ely of Death Foretold: 
Prophecy and Prognosis in Medical Care 

Benchmarks ...10 

How does the brain recognize die self? 
by Courtney Humphries 

Alumnus Profile 54 

A physician treats not only children 
with sports injuries, but also marathoners 
and ballet dancers. 
by Susan Cassidy 

Class Notes 56 

Obituaries 61 

Endnotes 64 

A comfortable pair of O.R. shoes can 
be a surgeon's best friend. 
by Lawrence Kadish 




Family Values 12 

A father passes on a legacy of caring for the underserved to his daughter. 


Everyday Heroes 18 

From urban health centers to African hospital wards, physicians 
struggle to make a difference in the health and hves of vulnerable people. 


Saints Alive 24 

Physicians find inspiration and guidance from both traditional 
and unexpected sources. 

The Golden Rule 30 

In the golden years of their retirement, doctors discover that the spirit 
of volunteerism yields rich rewards for both recipient and donor. 


The Last Home of Mystery 36 

■W$W-'^SSk 'AHHI A physician reflects on a half century 

of health changes in Nepal. 


Home Schooling 42 

while accompanying his father to conduct 
a health survey in Nepal, a son finds 
parallels with his own experiences in West Virginia. 


Days of the Dead 44 

A medical student sheds hght on the harsh realities of life — and 
death — for people with tuberculosis in Chiapas, Mexico. 


The Long Road to Longwood 50 

Family tragedy, generosity, and brilliant entrepreneurship all 
contributed to the inside saga of how the Francis estate provided 
the land for Harvard Medical School and Peter Bent Brigham Hospital. 


Cover photograph of Harold and Alison May by Tim Gray 

Harvarrl M eHiml 


In this Issue 


^^^nfl "Unsung Heroes" we quickly realized that there are myriad 
^^ l^l^^H forms of heroism in medicine, virtually all of them unsung. Who 
^H^l^HI could be more the heroine of her own life, to paraphrase Dick- 
ens, than a typical woman physician raising children? On this occasion, we 
decided we would focus on physicians who have taken physical, pohtical, eco- 
nomic, or emotional risks to provide care for underserved populations. 

That settled, we soon found that no one was volunteering to have his or 
her story told in our pages. Some potential subjects politely refused; others 
simply didn't return telephone calls. Still others seemed to have no fixed 
address, to be always leaving for another continent or an endangered neighbor- 
hood around the corner. Those whom we rounded up, and who appear in this 
issue, agreed in response to a degree of personal badgering on our part — and, I 
think, because this seemed to be a decent means to a good end: to use their 
own stories as a vehicle for telling their patients' stories. 

In reading these narratives — the physicians' and the patients' — what soon 
struck me was the utter falseness of a dichotomy I have long taken for granted, 
that service and research are somehow different. These are stories of service, 
over and over again, and what shines through is the extraordinary amount of 
intellectual effort required to provide good service to patients who are not 
schooled in the mores of proper patienthood or are not provided with the 
wherewithal to be taken care of in conventional settings. It may be a problem 
of cross-cultural semiotics; the physician attending a stoic, elderly Vietnamese 
man must learn that he communicates his pain and terror not with grimaces 
but by the presence of family members. It may be a problem of pohtical econo- 
my: the retired physician who wishes to volunteer his services to the indigent 
must analyze an elaborate system of well-intentioned regulations that work to 
preserve the very gap in care that everyone wishes could be fiUed. Such 
research may lack controls and clones, but it represents a very real foray into 
new areas of knowledge and a brave form of inquiry. 

As noted on page 5, the Bulletin was recently named a finalist for the 
National Magazine Award in General Excellence in the category of magazines 
with a circulation of less than 100,000. In the magazine world, these awards are 
the equivalent of Puhtzer prizes. The actual award was given to The American 
Scholar, whose editor, Anne Fadtman, is the author of The Spirit Catches You and You 
Fall Down. We are proud to be in this company, and I congratulate the editors of 
the Bulletin, Paula Byron, Beverly Ballaro, and Susan Cassidy, as well as former 
associate editor Phyllis FageU, and our design director, Laura McFadden, who 
have made this alumni magazine a serious contender for such an award. 


WilHam Ira Bennett '68 


Paula Brewer Byron 


Beverly Ballaro, PhD 


Susan Cassidy 


Elissa Ely '88 


Judy Ann Bigby '78 
Rafael Campo '92 

Elissa Ely '88 

Atul Gawande '94 

Robert M. Goldwyn '56 

Perri Klass '86 

Victoria McEvoy '75 

James J. O'Connell '82 

Nancy E. Oriol '79 
J. Gordon Scannell '40 
Joshua Sharfstein '96 

Eleanor Shore '55 
John D. Stoeckle '47 


Laura McEadden 

UMj^&M\ (aa ^ly^^y-Jt 


Charles J. Hatem '66, president 

Paul J. Davis '63, president-elect 1 

MitcheU T. Rabkin '55, president-elect 2 

Stephen G. Pauker '68, vice president 

Maria C. Alexander-Bridges '80, secretary 

Cecil H. Coggins '58, treasurer 


Rafael Campo '92 

Paul Farmer '90 

B. Lachlan Forrow '83 

Michael A. LaCombe '68 

Gina T. Moreno-John '94 

DeWayne M. Pursley '82 

Nanette Kass Wenger '54 

Francis C, Wood, Jr. '54 

Kathryn A. Zufall-Larson '75 


Daniel D. Federman '53 


Nora N. Nercessian, PhD 


Chester d'Autremont '44 

The Hanard Medical Ahmni Bulletin is 

published quarterly at 25 Shattuck Street, 

Boston, MA 02115 «? by the Harvard 

Medical Alumni Association. 

Phone: (617) 432-1548 . Fax; (617) 432-0013 


Third class postage paid at Boston, 

Massachusetts. Postmaster, send form 3579 

to 25 Shattuck Street, Boston, MA 02115 

ISSN 0191-7757 • Printed in the U.S.A. 





rr\ t:' ^n 



War Stories 

I read with great interest your article 
"When HMS Went to War" in the sum- 
mer issue of the Bulletin. My father, 
Bertram Trelstad, MD, was neither an 
HMS alumnus nor a faculty member, but 
by the vagaries of that time, he ended up 
being linked to the 105th beginning 
at Fort Lewis and staying with them 
throughout a three-year period in Aus- 
traha and New Guinea. 

hi 1966, when I graduated from HMS, 
my dad mentioned that Albert Coons 37 
had once been one of his colleagues. I had 
gotten to know Dr. Coons moderately 
well as a medical student, but he had never 
mentioned anything about my father or 
the 105th. One day, unannounced, we 
knocked on his office door in Building D. 
A voice invited us in, and when the door 
swung open. Dr. Coons glanced up and 
said, "Hi, Bert." I sat dumbfounded for the 
next hour hstening to stories that my 
father had never told my brothers or me. 

Later during the graduation events, we 
spent a lovely evening with Dr. and Mrs. 
John "Jack" Newell '30 at their home and 
then at the Harvard Club. That evening. 
Jack and my father reminisced about 
getting mail through the censors. Jack 
recounted how he had written his wife to 
let her know that they'd moved and where 
they actually were. The name of the new 
site — ^Toowomba in Queensland, Aus- 
traha — was, phonetically, "two wumba." 
Being a gynecologist, Newell drew a pic- 
ture on his letter of a bear with a bicornu- 
ate uterus — a "two-wombed bear." This 
got through the censor and Jack's wife 
decoded the message. Many laughs. 


Passage to India 

Reading the obituary page is generally 
a sobering pastime, but I discovered 
recently, to my surprise, that there are 
exceptions. In the autumn issue of the 
Bulletin, I came across the name of Reeve 
Betts 33. It sounded familiar and piqued 
my curiosity but I could not imagine 
why. I was sure that somewhere I had 

^^^E^". ' d-S^if'!':-' 




HARVARD'S HEROES: The hospital flagpole at Biak in New Guinea, where the 
105th General Hospital formed a surgical mobile unit during World War II. Many 
HMS alumni and Harvard-affiliated hospital staff members served in the 105th. 

known him, but try as hard as I could to 
place him, nothing happened. 

Then I read the entry and began to 
laugh. In Seattle more than half a century 
ago, I boarded a freighter that was bound 
for Singapore. Among the little cluster of 
12 passengers was a remarkable family 
named Betts who were making their ini- 
tial passage to India. Reeve, I remember, 
planned to start a new career as medical 
missionary in Vellore. His kids were hve- 
ly, entertaining, and well-behaved, and 
his wife, Martha, was a jewel. Like most 
freighter passengers who make a long 
ocean crossing, we bonded and promised 
to keep in touch. But we did not. After I 
said goodbye to them, I wondered for a 
long time about their fate. 

Now, 50 years later, thanks to your mag- 
azine, I have learned the happy ending to 
the story. Even though Reeve and Martha 
are gone, I still think warmly of their three 
htde children, who are now quite grown 
up. I wonder if they remember the journey 
and our encounter aboard ship. 



The Kindness of Strangers 

After reading Mark Adickes's speech 
"From Jock to Doc" in the autumn issue, I 
fondly remembered my husband's star- 
tling story of his acceptance to HMS in 
the fall of 1946: Robert Stier Morrison '50, 
a World War II veteran and Missouri 
native, was visiting a girlfriend (not me) 


. F T T E R S 


in Boston in August 1946. He had been 
accepted at the Washington University 
School of Medicine in St. Louis. Having 
some free time on his hands, Bob dropped 
in on the dean of HMS for a chat about 
medicine, career paths, and research. At 
the end of the talk. Bob was informed that 
HMS vv'ould be happy to accept him into 
the Class of 1950! This was a life-changing 
moment that dehghted Bob then and 
filled his life and work with pride from 
that day until he died in 1991. 


Making Up for Lost Time 

It is noted on the autumn Bulletin cover 
that the Class of 2000 and that of 1999 
both graduated more women than men. 
This is of some interest, as the 
first class to admit women was 
1949 and the second 1950. They 
were few in number and 
resented by a small number of 
faculty. Other schools had been 
graduating women before the 
turn of the century. Harvard is 
beginning to catch up! 



Having briefly sampled science as a 
laboratory technician, she entered HMS 
in the sixth class to admit women. That 
was midway in a ten-year experiment to 
see if women could succeed at HMS. 
To her classmates she was a studious, 
thoughtful colleague, balancing the 
advantage of her maturity with a ready 
wit and capacity for hard work. After an 
internship in pediatrics at Massachu- 
setts General Hospital, she began a com- 
phcated pattern that she described in her 
15th reunion report as a sequence of fuU- 
time residency, part-time residency, part- 
time chnical employment, and "multiple 
involvements that go with family hving 
in suburbia." That pattern, typical of the 
women physicians of her time, was a tri- 
umph of ingenuity and energy. 


Mary Smythe Coley '54 
was a particularly good 
example of a pioneering 

woman who reinvented her life and 

her career more than once. 

A Balanced Life 

In 2001 it is easy to forget how 
the early women graduates of 
HMS had to find their way 
professionally with few role models and 
scant social support for combining their 
careers with family hfe. In contemporary 
terms, these women had to invent and 
then reinvent themselves to meet their 
opportunities and challenges. 

Mary Smythe Coley '54, whose obitu- 
ary appeared in the summer issue of the 
Bulletin, was a particularly good example 
of a pioneering woman who reinvented 
her life and her career more than once. 
She trained as a pediatrician, made a life 
as a wife and the mother of three children, 
and in mid-life created a new profession- 
al identity as a child psychiatrist. She also 
had a full life of community service, 
which extended to the time of her death. 


In her reunion report of 1974, Mary 
applauded the "increase in humanitarian 
versus scientific attitude among stu- 
dents," reflecting the balance in her own 
life between her profession, her family, 
and community interests. Twenty-five 
years after graduation, she had once again 
increased her professional commitments, 
combining pediatrics with community 
service. The flexibihty to meet such spe- 
cial community needs was a Uttle-appre- 
ciated byproduct of the special nature of 
women's careers in medicine at that time. 

Mary's pediatric practice in the commu- 
nity opened her eyes to the multiple factors 
that contributed to patients' needs, and she 
decided on further training in child psychi- 

atry. With her children grown (one an 
intern in medicine at MGH), she moved to 
Boston for residency training in a Massa- 
chusetts Mental Health Center affiliated 
program and completed her child psychia- 
try fellowship at Brown. Trained in both 
adult and child psychiatry, she returned to 
Hartford to construct an active hfe of pri- 
vate practice, teaching, and consulting at 
the Institute of Living, along with serving 
as a psychiatric consultant for The Street 
Ministry of West Hartford. The director 
wrote at the time of her memorial service, 
"With the changes in mental health insur- 
ance coverage, she became an invaluable 
backup for The Street Ministry....She was 
smart, insightful, and compassionate. She 
supported kids, parents, school personnel, 
and The Street Ministry as she sought to 
make sure that no child in West 
Hartford went without access 
to mental health treatment. 
Mary cared" 

like so many of the early 
HMS women, Mary's reinven- 
tions of herself left her realistic 
about the past but pleased with 
the life she had created. In her 
last reunion report, in the year 
before she suddenly died with a 
pulmonary embolus, she wrote: 
"I regretted not being able to do 
training as fast as it was possible 
when raising children. I am glad 
now that the larger system is 
coping better with the needs of women 
physicians with a different community 
attitude — much better day care and 
preschools. It's aU more positive. However, 
I went in the direction I wished: pediatrics, 
then psychiatry, and now child and adoles- 
cent psychiatry — and that is fine." 


T?ie Bulletin welcomes letters to the editor. Please 
send letters hy mail (Harvard Medical Alum- 
ni Bulletin, 25 Shattuck Street, Boston, Mass- 
achusetts 02115); fax (617'432WB); or email 
( Letters may he 
edited for length or clarity. 



_Xl LJ I ^ ^ 

Building a Foundation for the Future 



Martin welcomed city, communi' 
ty, and university dignitaries and 
more than 100 invited guests to 
the ceremonial groundbreaking for the 
School's new research buHding on Avenue 
Louis Pasteur. Anchoring the campus's 
new North Quad, the structure will add 
about 430,000 square feet of research 
space to the School, including a ten-story 
tower. The new building will help meet 
demand for facilities that support the 
advanced investigations being conducted 
at HMS and its affiliated institutions, 
including initiatives on Alzheimer's, dia- 
betes, heart disease, stroke, infectious dis- 
eases, and cancer. The building is slated 
for completion in 2003. 

The $250 million project includes 
research space being designed with adja- 
cent laboratories housing related work and 
sharing core facihties that are too expen- 
sive for a single faculty member to main- 
tain independently. Such core facihties are 

a hallmark of the interdisciplinary research 
being conducted at HMS. 

The research building vwll also provide 
common areas — such as kitchens and 
lounges — for fostering the informal dis- 
cussion that is at the heart of much scien- 
tific collaboration. 'This is a wonderful 
opportunity to get a group of like-minded 
researchers together on a more intimate 
basis — great things happen around those 
water cooler conversations," said Susanne 
Churchill, associate dean for research. 
Adjacent floors between the new build- 
ing and the Harvard Institutes of Medi- 
cine will be connected by causeways 
and will, in many cases, contain similar 
research functions. 

"Biomedical research is at a threshold of 
opportunity based on genomic research 
and other breakthroughs," Martin said at 
the ceremony. "By having hospital-based 
faculty and basic scientists work side -by- 
side, the translation of research from 
bench to bedside will be hastened." ■ 

DIGGING IN: Lending a hand at the groundbreaking for the Medical School's 
new research building are, from left: Mark Moloney, director of the Boston 
Redevelopment Authority; Harvard University President Neil Rudenstine; Boston 
Mayor Thomas Menino; and HMS Dean Joseph Martin. 

Still the One 

For the 1 2th consecutive year, 
HMS has been ranked as the 
best American research medical 
school by U.S. 
News and 
World Report. 
The School's 
in women's 
health, geri- 
atrics, and 
internal medi- 
cine were ranked number one in 
the specialty rankings, while the 
pediatrics program was ranked 
second. The programs in drug 
and alcohol abuse and AIDS 
were both tied for the number 
two ranking with Johns Hopkins. 

We're Honored 

This spring, the Harvard Medical 
Alumni Bulletin was named a 
finalist for the National Magazine 
Award in General Excellence, the 
magazine industry's most presti- 
gious award. In the category for 
magazines whose circulations are 
under 100,000, the Bulletin was 
honored for its special issues on 
medical ethics, medical detectives, 
and physician renewal. 

The Bulletin also received a 
merit award from the Society of 
Publication Designers in an annual 
competition that attracted nearly 
8,000 submissions. The award 
was conferred for the cover design 
of the Winter 2000 issue, "Med- 
ical Ethics: From Conception to 
Death," which featured a tiny baby 
being cradled in a man's hands. 

Finally, the Bulletin received a 
bronze medal from the Council for 
the Advancement and Support of 
Education in the category of peri- 
odical staff writing. 



The MEC Shall Inherit the Earth 



the HMS Second Year Show, "Corporate Looteum: 
The MEC Shall Inherit the Earth" — a three-hour 
musical extravaganza that showcased the 
diverse talents of the Class of 2003. 

It was inevitable that this year's 
parody of life as a second-year stu- 
dent at HMS would focus on the 
School's new dean for medical 
education, Daniel Lowenstein '83 
(portrayed by Taylor Ortiz). But 
his predecessor, Daniel Federman 
'53 (Eric Rosenthal), made his pres- 
ence known as well. The show's premise: an 
"evil" Federman decides to franchise HMS, set- 
ting up second-rate copies of the School around 
the globe to lure away HMS students and pro 
lessors — much to the consternation of 
Lowenstein, who sends a group of concerned 
students on a mission to find out 
what's going on at these "other" 
Harvard Medical Schools. 

This setup gave the Class of ; 

2003 an opportunity to cele- 
brate the cultural offerings of 
various international locales. 
Audiences were treated to tradi- 
tional dance at the HMS India franchise; a flamen- 
co number at HMS Spain; salsa dancing at HMS 
Puerto Rico; and at HMS China, a graceful ribbon 
dance that morphed into a high-powered martial 
arts display. 


And then there were the songs, which 
parodied everything from indi\Tdual profes- 
sors to the New Pathway curriculum. Female stu- 
dents paid tribute to anatomy professor Farish Jenk- 
ins, in an ode sung to the tune of Madonna's "Cherish." 
The show took a swipe at materialistic MDs at HMS 
Switzerland, where students in business suits, led 
by Charmaine Smith, sang "I'm Selling Out," to 
the tune of Diana Ross's "I'm Coming 
Out." A sample lyric: "There's a new 
me seUixig out/'Cause docs don't 
make a lot/Respect is what you've 
got/But I'd really like a yacht." Har- 
vard School of Dental Medicine stu- 
dents attacked tooth decay at — 
where else? — HMS England. And at 
HMS Spain, professors Bruce Korf (Joseph 
Carlson) and Chff Tabtn (Tom Richards), along with their 
respective fans, faced off in a battle, complete with 
swordfight, set to the tune of a song from Disney's Mulan. 
In the end, of course, students and teachers were 
reunited at HMS Longwood, thus thwarting Dean 


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students kick up 
their heels in a dis- 
play of traditional 
dance. B. Kung-fu 
fighters sho>v off 
acrobatic moves. 
C. Harvard's sen- 
sory homunculus 
helps students 
learn about neuro- 
anatomy. D. Coun- 
second years sing 
about complex 
diagnoses. E. A 
student conducts a 
patient interview, 
"Southie" style. 

Federman's evil plan to franchise the School (and while he's at it, 
destroy the world). The show concluded with an HMS version 
of "One" from "A Chorus Line," in which students sang, "One 
look at our skills on the stage and you will see/Why we're 
forsaking the theater for our MD." Despite that disclaimer, audi- 
ence members thoroughly enjoyed the Second Year Show, shout- 
ing out their approval at particularly apt bits of satire or well- 
executed dance moves and acrobatics. 

Rehearsing those moves took its toll, however; Janet Mal- 
donado, who produced the show with Joseph Carlson and Jen- 
nifer Lee, reports that the dance rehearsals were grueling at 
times, and resulted in quite a few bruises and pulled muscles. 
But the intense preparation paid off. "I knew our class was 
made up of very talented people," Maldonado says, "but this 
display of talent on stage was unexpected for everybody." ■ 


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Alumni Council's winter 
meeting on March 1 and 2 
was the welcoming of 
Nora Nercessian, assistant dean for 
alumni affairs and special projects, as 
the newest honorary member of the 
Harvard Medical Alumni Association. 
Only twice before in its history has 
this distinction been conferred (on 
Dorothy Murphy and Ellen Miller). By 
unanimous vote of the Council, Nora 
was recognized for her commitment 
to the HMAA and for her unique per- 
spective, as a historian, in preserving 
its history. 

The certificate of award read: 
"Know ye that in recognition of her 
extraordinary efforts at preserving the 
spirit and history of Harvard Medical 
School, Nora N. Nercessian, PhD, has 
been elected an honorary member of 
the Harvard Medical Alumni Associa- 
tion, March 3, 2001." 

Our congratulations as well to our 
colleagues at the Bulletin for receiving a 
merit award from the Society of Publi- 
cation Designers for the cover design 
of the Winter 2000 issue, which was 
devoted to medical ethics. 

The state of medical education at 
HMS was a central theme of the winter 
meeting. At the Council's dinner, 
Joseph Carlson '03, Lynn Sosa '02, and 
Stephen Martin '02 offered their view- 
points, as current students, as to the 
educational and training strengths and 
weaknesses of the present curriculum. 

At the following day's session, 
Steven Weinberger '73 provided the 
faculty's perspective. His analysis of 
the challenges of clinical education 
extended the students' insights into 
problems as seen and experienced by 
the housestaff, faculty, HMS and the 
academic medical center. He reviewed 
current initiatives that speak to the 
needs of each of these groups. The 
morning concluded with a discussion 
with Dean Joseph Martin about the 
educational and research initiatives in 
the Quadrangle. 

The meeting also provided a rich 
discussion of the Coleus Society by 
Pete Coggins '58 and Joseph Hurd '64. 
The Coleus Society, approved by the 
Alumni Council in 1988, was estab- 
lished, according to Michael Myers '85 
and Bernard Godley '89, with a central 
commitment to enhancing network- 
ing among minority alumni, by serv- 
ing as mentors and role models for 
current HMS students, and by 
increasing social interaction among 
minority graduates and all HMS grad- 
uates. Current strategies for the con- 
tinued accomplishment of these goals 
were reviewed. 

After lunch, the Council toured the 
newly refurbished Countway Library, 
conducted by Judith Messerle, head 
librarian. Of particular interest was 
the demonstration of the digital 
library resources permitting broad 
access to the literature on-line. 

Lastly, plans to initiate a web-based 
survey of the alumni were discussed. 
The Council anticipates a pHot survey 
this spring in advance of a larger effort. 
John Halamka, MD, associate dean of 
educational technology, presented his 
experience with web-based surveys and 
will assist in estabhshing the computer 
infrastructure for the alumni effort. The 
notion of periodic web-based surveys, 
which will also serve as a communica- 
tions link, continues to have the enthu- 
siastic support of the Council. 

Alumni Week is right around the 
corner. The Friday morning session 
will be devoted to the topic of renew- 
al, and we hope that you will come 
and participate. We look forward to 
seeing you then! 

As always, your views and counsel 
about the work of the Council are most 
welcome. Please contact Dan Feder- 
man, Nora Nercessian, or me through 
the alumni office (phone: 617-432-1560; 
email: ■ 

Charles ]. Hatem '66 is director of medical 
education at Mount Auburn Hospital in 
Cambridge, Massachusetts. 



Left Bank 

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home. The period decor includes all 

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Varenne, 7th Arrondissement. Maid 

service and our Guide to the Best of Paris 

are included for free. 



We offer rental of our wonderful home 
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and is carefully tended, perfect for 
honeymoons and relaxing vacations. 
Maid service and our Guide to the Best 
of St Barts are included free of charge. 

(650) 327-2415 





We are offering for sale the two original 
chandehers removed from Harvard Medical 

School's VanderbUt HaU in Boston. These 

important chandehers, circa 1925, are 7 feet 

high and 5 feet wide, sohd brass, very high 

quahty and complete with the Harvard 

insignia embossed on the ball. They have 
been professionally restored by our crafts- 
men. If still available, they will be featured 
on eBay from July 10 to July 20, 2001. 

Qanktt Olraltaman 


(508) 653-0031 



Death Foretold 

Prophecy and Prognosis in Medical Care 
by Nicholas A, Christakis '88 
(University of Chicago Press, 1999) 


doctor. You need to know three things from her: 
what's wrong with me? how will it be treated? 
and, will I survive? It's the last trembling question 
about prognosis that is most personally imperative, most 
sudden, and most difficult to answer. 

In the constantly revised textbook Harrison's Principles of 
Internal Medicine, only 27 percent of the authoritative entries 
contain prognostic information. In a 15'minute medical visit, 
the median amount of time devoted to delivering a prognosis 
is three seconds. These creative statistics — and the book 
Death Foretold is dense with them — can stop you dead. There 
is no denying it. Prognosis is in desperate need of a 
second life. 

Prognosis is the neglected child of two 
overworked professional parents, diagno- 
sis and treatment. Textbooks omit it, med- 
ical schools don't teach it, doctors avoid it. 
As author Nicholas Christakis '88 writes, 
"Like death, prognostication seems mysteri- 
ous, final, powerful, and dangerous." 

Christakis then takes 300 rigorous pages 
to enter the belly of the beast and look 
around with a bright light. Using the old psy- 
chiatric saw that insight can combat instinct, 
he begins with the many reasons we dread 
telling patients what will happen to them. 
Some seem sensible: fears of being sued by a 
patient, and fears of losing stature in front of 
colleagues, when a prognosis is inaccurate. Some seem more 
primitive: superstitions that delivering a prognosis, especial- 
ly a favorable one, throws a challenge to the gods and invites 
failure. Some are personal: reluctance to bear bad news (go 
figure, without stereotyping, why prognoses are delivered 
most often by surgeons). Some are well-meant: doesn't bad 
news deplete hope, and isn't hope necessary? 

Then there are technical difficulties. Prognoses are hard to 
formulate accurately. They become Heisenbergian, since 
using a treatment to shine a light on illness actually changes 
its position over time. What began as an accurate prognosis 
is altered by medical response. 

There are plenty of reasons why the neglected child is 
left to itself. Yet our job is to discover, to treat, and to tell. 
Christakis argues that prognostication is necessary for 
both patients and doctors. Whether bright or dim, progno- 
sis decreases uncertainty and anxiety. When it is correct, it 

confirms that the unknown is less unknown. When it is 
incorrect, it inspires the grand sense (in patients and care- 
takers) that some larger force has rolled their dice differ- 
ently. As Christakis states, it "evokes religion in a way that 
diagnosis and treatment.. .much more under human con- 
trol, do not." 

There is a vision in this book, a shining picture of what the 
ideal prognosis would be like, and the writer goes to great 
lengths to illuminate it. The ideal prognosis requires prepa- 
ration. It should be grounded in research and studies on par- 
ticular diseases — "no matter how difficult it may be for 
physicians to foretell the future, they can make more of an 
effort to foresee it." Its delivery should be practiced and prac- 
ticed again, like any technical skill, in medical school. It 
should be given in absorptive stages, not in a single dose of 
"terminal candor." It should accomplish what seems impos- 
sible: offer accuracy, yet sustain hope. 

To do this, the ideal prognosis makes use of 
two kinds of knowledge: objective and 
empathic. Christakis suggests that special- 
ists, with less personal knowledge of a 
patient but more objectivity, are best able 
to develop the prognosis. Generalists, with 
longitudinal knowledge of the person in 
each of their patients, are better able to 
communicate it. This seems at once an obvi- 
ous and a daring idea. 

The most powerful proofs of Christakis's 
vision come from the stories doctors tell 
about themselves, transcribed without tidy- 
ing up grammar or vernacular, full of pipe 
smoke circling over the general practitioner's 
head and consoles beeping in the ICU, These 
voices make up the components of a single complicat- 
ed being: reflective (a hospice doctor asking his terminal 
patient about her hopes and dreams); flippant; abrupt; 
defensive (a specialist castigated by his patient for having 
removed all hope); wrung out (an ICU intern hating the 
dying patient he must keep alive for the family); tearful (an 
oncologist glossing over terminal news to a young mother 
with ovarian cancer); and touching. 

The drive behind great thinking is always personal. "I 
spent my boyhood.. .both craving and detesting prognostic 
precision," Christakis writes in his dedication. When he was 
six years old, his mother was given a 10 percent chance of liv- 
ing three weeks. She lived for another 19 years. Some physi- 
cian had the courage to deliver this news. The family had the 
courage to hear and accept it, and then to revel in its wrong- 
ness. Without doubt, the doctor reveled, too. It was a prog- 
nostic dream come true. ■ 

Elissfl Ely '88 is a lecturer on psychiatry at HMS. 




Right on Target: Recognizing the Self 


and left brain hemispheres 
has become part of our lore, 
with frequent references in 
popular culture to "right-brain think- 
ing" or "left-brain people." The reality 
is not that simple, but many of the 
brairis functions do display a degree 
of lateralization, and scientists often 
treat the left hemisphere as the better 
half, with its superior abilities in lan- 
guage, problem solving, and logic. The 
differences in awareness between the 
two hemispheres have even been com- 
pared to those between humans and 
other species. But research led by 
Julian Keenan, HMS instructor in neu- 
rology, and Alvaro Pascual-Leone, 
HMS associate professor of neurology, 
both at Beth Israel Deaconess Medical 
Center, shows that self-recognition. 

one of the hallmarks of human con- 
sciousness, may be largely a function of 
the right hemisphere. 

Face Value 

Many primates can distinguish faces, 
yet the ability to recognize one's own 
face in a mirror is one that only higher 
primates have, suggesting that self- 
recognition may be linked to a higher 
order of self-awareness. Research has 
pointed to the involvement of the pre- 
frontal cortex of the right hemisphere 
in seK-recognition; for instance, func- 
tional imaging shows increased activity 
in the right prefrontal cortex when sub- 
jects are comparing images of self with 
others, or identifying attributes associ- 
ated with self. But imaging can be noto- 
riously vague. It shows active areas of 

IDENTITY CRISIS: Julian Keenan, right, is shown morphed with a picture of Bill 
Clinton. Patients 'who looked at similar images of themselves morphed 'with a 
famous person recognized themselves in the picture when using their right brain; 
while using their left brain, patients recognized the celebrity. 

the brain but cannot prove a causal 

The team's current experiment goes a 
step beyond looking for correlations by 
actually blocking a portion of the brain 
to determine if it is needed for a task. 
The group studied five patients under- 
going a preoperative test for surgery to 
treat epilepsy. During the test, half of 
the brain was anesthetized, blocking it 
temporarily. While under anesthesia, 
each patient was shown and told to 
remember an image of his or her own 
face morphed with that of a famous per- 
son. After the anesthesia wore off, the 
patients were presented with the two 
pictures that had been morphed together 
and instructed to choose which image 
they had seen. 

Although neither image was correct, 
patients chose the image they thought 
most closely represented the one they 
had viewed. All of the patients who had 
seen the morphed picture with the left 
half of their brain blocked chose the pic- 
ture of themselves. Yet four out of five 
patients who had looked at the morphed 
picture with the right half of their brain 
blocked chose the famous person. "In 
these subjects," Pascual-Leone says, "how 
likely they are to recognize themselves 
in a given equivocal picture is much 
higher if they can use the right hemi- 
sphere than if they can't." 

Taking Sides 

Although the study supports the theory 
that the right brain is involved in self- 
recognition, how to interpret this asso- 
ciation is still unclear. With an organ as 
complex as the brain, it is dangerous to 
assume that an area crucial to perform- 
ing a certain task actually contains this 
ability. "There is something critical in 
the relationship of the right frontotem- 
poral area to the seK and self-aware- 
ness," Pascual-Leone says. "But it doesn't 
mean that that's where the self is." 

One possibility is that the left brain, 
with its superior access to language, is 
able to assign a name to the famous per- 




son more quickly, whereas the right 
brain, which is often hnked to the emo- 
tional response to language, responds to 
an unconscious emotional reaction to 
seeing oneseK. 

Alternatively, or perhaps in conjunc- 
tion with an emotional response, it is 
possible that a network in the right 
brain is involved in many different 
aspects of self-awareness. Studies of 
patients with lesions on the right pre- 
frontal cortex also provide anecdotal 
evidence of this relationship. Case stud- 
ies have documented people with dam- 
age to the right prefrontal cortex who 
experience impaired autobiographical 
memory, depersonalization, or denial of 
ownership of the left side of their bodies. 
"I'm interested in finding out if there is a 
relationship in all this," Keenan adds. 
Although there may not be anything so 
simple as a self "center" in the brain, 
Keenan says, the current study "allows 
us to add weight to the notion that some 
specific area or network that includes 
right frontal areas has something to do 
specifically with this idea of self." 

Keenan has devised other ways of 
testing the brain's lopsided sense of 
self-image. His team has used trans- 
cranial magnetic stimulation on normal 
subjects to show that the right side of 
the brain is more active when looking at 
morphs of oneself. He has also used the 
techniques of morphing faces to create 
movies that show a gradual transition 
from one face to another. Subjects were 
then instructed to press a button when 
they recognized that the famous face 
had become either their own face or the 
face of a coworker. The average stop- 
ping point arrived sooner when sub- 
jects were looking at themselves and 
responding with their left hand, which 
is controlled by the right hemisphere. 
"The question is," Pascual-Leone says, 
"when something equivocal is in a face, 
do you recognize it as being yourself or 
not, and how quickly?" ■ 

Courtney Humphries is a science writer for 
Focus, a hiwcckly newsletter published at HMS. 

THE APERTURE PROBLEM: A vertical bar is shown at five 
positions as it moves upward and rightward. But vt^hen the 
bar is vievred through a small window, analogous to a single 
neuron's receptive field, it seems to move only to the right. 


hen interpreting movement in the visual v/orld, the 
brain must integrate information from many different 
neurons in the primary visual cortex, each of v/hich 
has a tiny receptive field. From all of these localized 
snapshots the brain must somehow construct the 
whole picture. But how does it make an interpretation when the 
snapshots offer conflicting information? 

In the illustration above, a vertical bar is shown at several posi- 
tions in time as it moves in a diagonal direction upward and to 
the right. But when viewed through a small window that does not 
include the endpoints of the line, it seems to have moved in a per- 
pendicular direction to the right. If the window represented a cell's 
receptive field, interpreting direction of movement could be mis- 
leading because only cells that are positioned at the endpoints of 
the line can register the true direction. 

Richard Born '87, HMS assistant professor of neurobiology, and 
Christopher Pack, a research fellow in his laboratory, report in the 
February 22 issue of Nature that the middle temporal (Ml) visual area 
has a dynamic solution to the problem. Using microelectrodes, they 
measured neuronal responses in alert macaque monkeys who were 
shown lines moving at different orientations. How the visual part of the 
brain interpreted the direction of movement could be determined by 
the firing of direction-selective MI neurons. The team found that the 
MT initially responded primarily to the perpendicular component of the 
movement, consistent with the idea that more neurons ore registering 
only this direction. But over a period of about 60 milliseconds, the 
neurons gradually register the true direction of movement. 

"The brain makes a very quick guess," Born says. "It takes time 
for the right answer to percolate." The monkeys also mode initial eye 
movements that deviated in the direction perpendicular to the lines, 
suggesting a behavioral correlate of the early neural response. ■ 




as both an idealist and a realist. His is a vision born of growing 
up surrounded by powerful, practical models of good and evil 
in the world beyond his home in Poughkeepsie, New York. 
May's father, a minister in the African Methodist Episcopal 
Zion Church, and his mother sparked an early desire in their 
son to pursue missionary work. The inspiration to combine this 
spiritual endeavor with medicine arose when a friend of May's 
father made a providential gift of several books on Albert 
Schweitzer's life and work in Africa. 

At the same time that Harold May was making adolescent 
acquaintance with Schweitzer's humanitarian work, he and 
his generation were coming to grips with the horrors of the 
Holocaust. The idealistic and faithful young man learned stark 
lessons about the need to fight for justice when the occasion 
demanded it. He was a high school student when World War 
II broke out, and 17 years old when he volunteered to join the 
Air Corps, where he trained as a pilot. When the war ended, )> 

Harold May passes on a legacy of compassion to his daughter Alison 

by Beverly Ballaro 



had always known she would 
follo'w in the footsteps of her 
father, Harold, and her mother 
in caring for the needy. 


\ «' 



I never 

once asked God for my vision 
will, no matter what that was. 

May opted to leave the military because 
he knew that he wanted a career in 
heahng people, both physically and 
spiritually. After completing his pre- 
medical studies at Harvard, he enrolled 
at HMS, where he quickly discovered 
that the medical profession suited per- 
fectly the man he was and the man he 
wanted to become. 

Blind Faith 

May sailed through his first year of 
medical school, impassioned by his 
dreams of bringing desperately needed 
surgical skills to Africa or India. But 
during his second year at HMS, May, 
the former military pilot, suddenly 
began having trouble seeing the black- 
board from his customary seat in the 
back of the amphitheater. An ophthal- 
mologist made the diagnosis of kerato- 
conus, possibly the result of an earlier 
injury. May's dreams of becoming a sur- 
geon began to slip away. 

Hard contact lenses, the only type 
available at the time, helped but, during 
his residency at Boston City Hospital, 
May discovered that this type of lens 
always produced an hour-long inflam- 
matory reaction. He began rising early 
to anticipate and plan around this reac- 
tion. As a medical consultant to the 
surgical service, he regularly scrubbed 
in for operations, which reawakened 
his desire to be a surgeon. He took a 
gamble by enrolling in surgical training 
despite his continuing vision problems. 
"I decided that I would walk by faith," 
he said, "and that it would all work out. 
I just didn't know how." 

May's faith in God's plan was bol- 
stered when he was accepted to the 
surgical program at Massachusetts 
General Hospital, the one and only 
place he had apphed. On his very first 
day at MGH, he met an ophthalmology 
resident, who gave him cortisone drops 
that ended his vision problems for the 

next two and a half years. Yet the eye- 
strain produced by prolonged contact 
lens use took its toll and, halfway 
through his training. May developed 
corneal ulcers in both eyes. For a time, 
he rotated a patch and contact lens but, 
eventually, both eyes gave out. May 
found himself legally blind, unable to 
navigate his way to the dining hall 
unless it was on the arm of a friend. 

Yet, despite the crisis. May's spiri- 
tuality never wavered, and even deep- 
ened at this time: "I was living by faith, 
not by sight. I never once asked God 
for my vision back. I just prayed that I 
would do His will, no matter what 
that was. My attitude was, 'Okay, 
what's next?'" May offered his resigna- 
tion to the chief of surgery at MGH, 
Edward Churchill, who refused to 
accept it, promising him that they'd 
try to get him corneal transplants. 

With no choice but to give his eyes a 
chance to heal to prepare for the trans- 
plants, May took a leave of absence and 
returned home to his parents. There, 
Reverend May took to reading aloud to 

his blind son. May recalls that one article 
his father read to him described the 
Albert Schweitzer Hospital in Haiti. 

By then. May had grown disenchant- 
ed with Schweitzer's notion of "bearing 
the white maris burden" in Africa. He 
had come to the conclusion that human 
efforts alone, even those of as great as a 
man as Schweitzer, would never be suf- 
ficient unless harnessed to a greater 
power. "I was looking to serve as God's 
instrument," he says, "but I had no idea 
at that time that His plan would set me 
on a path to the Schweitzer hospital." 

When a donor eye became available. 
May underwent the corneal transplant. 
The procedure was so new and the out- 
come so uncertain, that both May and 
his ophthalmologist had refused to 
do the operation until he was blind 
and there was nothing to lose. His eye 
remained bandaged for ten days. "I can 
remember so clearly," he says, "the ela- 
tion I felt when a nurse finally removed 
the dressing and I could see her." 
Up until that moment, blindness had 
remained a very real possibility for him. 

HEALERS IN HAITI: Harold May (right), Frank Lepreau, Jr. '38 (left), and a visiting 
surgical resident in front of the Schweitzer Hospital in Haiti. 



back. I just prayed that I would do His 
My attitude was, "Okay what's next?" 

Man on a Mission 

Hoping to convince their son to do mis- 
sionaxy work in their native Jamaica, 
May's parents invited him on a trip there 
while he was convalescing from his first 
corneal transplant. May ended up stay- 
ing for six months, during which time he 
studied tropical medicine and kept 
hearing more and more about the terri- 
ble poverty in nearby Haiti. The day 
after the 1956 Christmas revolution in 
Haiti, May was on board the first post- 
uprising fhght into the country. 

A local doctor in Port-au-Prince 
introduced May to some missionaries, 
who led him to the country's interior 
and Larry Mellon's Schweitzer Hospi- 
tal, the same one that May's father had 
described aloud to his bUnd son some 
months earher. May told Mellon, "I feel 
called to be a missionary and I'm look- 
ing for the place where I should spend 
my life," to which Mellon replied, 
"Well, can you help us right here?" 

May stayed at the hospital for six 
months, operating with only one good 
eye, and starting Bible study and hteracy 
classes in what little spare time he had. 
He went back to the United States to 
have his other eye surgically repaired and 
to complete his residency, then returned 
to Haiti, where he became both chief-of- 
surgery at the Schweitzer Hospital and 
lay pastor for the church. Several years 
later, Frank Lepreau, Jr. '38 joined the 
hospital as its medical director. May and 
Lepreau worked closely together for 
many years to alleviate the suffering of 
their patients, many of whom had never 
had access to medical care. 

During the nearly dozen years May 
worked in Haiti, he learned many valu- 
able lessons from his deeply impover- 
ished and mostly illiterate patients. 
Rural Haitian culture offered impressive 
models of rich family Hves and enduring 
faith in the face of adversity. But it also 
gave May stark insights into inequities 

in health across the board. "Yes, Haiti 
had enormous problems," May says. "But 
we should not delude ourselves into 
thinking that American culture is supe- 
rior. In my entire time there, I saw not 
one case of lung cancer. During my sur- 
gical training, I became accustomed to 
finding arteries as hard as stovepipes. 
But our Haitian adult patients had ves- 
sels as soft as those in babies. So, who is 
to say who was better off? Americans 
suffered from excess in their lives, while 
Haitians didn't have enough. The answer 
was for us to share resources and both 
be healthier for it." 

May was also deeply committed to 
the idea of empowering the Haitian 
people to help themselves over the long 
haul. "Rather than just cutting out 
tumor after tumor," he says, "I felt that 
the best investment of my energy would 
be to spend part of my time focusing on 
the education system, so that children 
would grow up with sound ideas about 
disease prevention. The hope was that 
some of them would eventually become 
teachers and doctors themselves." 

So, in 1962, May and the other mem- 
bers of the church decided to use the 
modest sum of money they had collected 
to start a kindergarten. They created 
space for 75 children; on the first day, 750 
showed up. Every year, another class 
was added to Ecole la Providence until 
1969, when the primary school was com- 
plete. When Mellon decided the school 
should grow no larger. May decided that 
it could continue to expand only if he 
left Haiti. For May, it was a test of faith. 
Despite their differences, he and Mellon 
remained good friends in the years that 
followed, as the school continued to 
grow and its influence to spread. 

Agent of Change 

God closes one door and opens another, 
the proverb goes; May quickly discov- 
ered that he could apply the lessons he 

BACK FROM THE BRINK: A 12-year-old Haitian 
patient, six months after May performed a 
spleno-renal shunt for portal hypertension. 

had learned in Haiti in the service of 
causes closer to home. When Grant 
Rodkey '43A, who had spent a month in 
Haiti, relayed the news that Francis 
Moore '39 wanted May to take on the 
job of director of community medicine 
at Peter Bent Brigham Hospital, May 
followed his calling. 

When Moore asked him to focus on 
finding ways to improve Boston's emer- 
gency services system. May collaborated 
with MIT professors and others to devel- 
op the best approach possible. Yet even 
as he worked to effect positive change, he 
found himself disheartened by the new 
vision of medicine that had taken hold 
while he was in Haiti. "I had always 
thought that being a doctor was about 
taking care of sick people," he says. "But I 
came back to a culture in which hospi- 



y father 

was always an 'island 
the right thing for the 

tals were clearly competing with one 
another and terms Kke 'health care con- 
sumer' were beginning to circulate as 
medicine moved into the marketplace." 

When an opportunity to work 
directly with another badly under- 
served population arose. May respond- 
ed. In 1975, a successhjl lawsuit against 
the commonwealth of Massachusetts 
required improvements in the treat- 
ment of mentally retarded people. 
When Children's Hospital accepted 
responsibihty for the medical services at 
what was then called the Wrentham 
State School, May and a colleague went 
to visit the place. "The conditions were 
really terrible," he recalls. "After seeing 
how overcrowded and understaffed the 
facility was, my colleague admitted, 'I 
could never work here,' but I said, 'I can.' 
In so many ways, it was just like Haiti." 

May spent 19 years at Wrentham, 
during which time conditions for its 
mentally retarded residents improved 
tremendously. As he had done in Haiti, 
where he had helped train nonprofes- 
sionals to function as physician assis- 
tants, here, too, he was pleased that 
nurse practitioners played key roles as 
"physician-extenders." When Children's 
decided, in 1994, to hand over responsi- 
bility for Wrentham to a new group. 
May faced a choice about whether to 
stay or to move on to a new calling — 
Boston's inner city. 

Family Footsteps 

"I really didn't know what God had in 
store for me next," May says, with a soft 
laugh, "but I figured He would provide 
an answer." Within days of May's 
departure from Wrentham, an issue of 
Time magazine arrived. The cover story 
described the short and troubled life of 
an 11-year-old Chicago boy who had 
murdered a young girl and had subse- 
quently been shot to death himself. 
Suddenly, just as with Haiti and Wren- 

tham, May knew what he had to do. He 
would work with troubled children 
and families in Boston's inner city. 

From his earUest days at HMS, May 
had loved learning about the body's sys- 
tems, how they work together, and the 
results when they are not in harmony. 
At Wrentham, he had seen how the cen- 
tral nervous system damage in mentally 
retarded people affected so many areas 
of their existence. And, now, thinking 
about the witch's brew of factors that 
was producing a wave of young kiUers 
and murder victims, May could see that 
the chaos of the internal systems of 
many of these troubled young people 
reflected the toxic environment that 
surrounded them. He could perceive in 
a new way that society was sick, and 
that its iUness was systemic. Society's 
systems — ^whether health care, educa- 
tion, or the economy — ^were not func- 
tioning in harmony, as they should. 

A vision for systematic change came 
to him in the middle of the night. May 
conceived of a membership organiza- 
tion called FAMILY ("Fathers And 
Mothers, Infants, eLders, and Youth") 
as a catalyst for the formation of a sup- 
port system for parents and children, 
and an agent for reahgning society's ail- 
ing systems. Drawing upon the school 
model initiated in Haiti, May's group 
hired a family educator to establish 
ongoing, nurturing relationships with 
all 25 kindergartners and their famihes 
at the Lucy Stone School in Dorchester. 
By repeating this effort with each enter- 
ing class. May knows that, in five years, 
all children at the school should have a 
support system in place. 

But May's experience has taught him 
the need to engage all of society's sys- 
tems. So, his group has started separate 
programs at Dorchester District Court 
for nonviolent fathers and mothers on 
probation. And, most ambitious of all, 
they are coUaborating with the Codman 
Square Health Center to estabffsh a 

support system that will follow all Cod- 
man Square newborns and their fami- 
hes throughout their hves. FAMILY is 
also establishing a think tank called the 
Family Institute for ongoing evaluation 
of the Codman Square experience as a 
rephcable model for other communities. 

May prizes his relationship with his 
own family as the main priority in his 
life, second only to his relationship with 
God. "I was always very busy as a doctor, 
but my family knew that I would drop 
anything for them," he says. Although 
May and his wife, Aggie, a nurse, were 
careful not to try to steer their three 
daughters toward careers in health care, 
Jeannette is a health educator, Margie is 
a nutritionist, and Ahson (HMS '91) is a 
physician with the Boston Health Care 
for the Homeless Program. 

The legacy of caring that May and his 
wife have transmitted to their children is 
part of May's greater life goal: "I'm sure 
that our society will become healthy only 
when we learn how to develop strong 
support systems for all children and all 
famihes. It won't happen during my life- 
time, but we must start. I hope and pray 
that it v^dU happen after I'm gone." 

Passing the Torch 

When Ahson May '91 received her HMS 
degree nearly 40 years to the day after 
her father's graduation, it was the fulfill- 
ment of a legacy that was not as preor- 
dained as it might have seemed. "We 
talked about it intermittendy," she says, 
"but my father never pushed me into 
medicine. He has always beheved that 
the commitment to be a good doctor has 
to come from within. He encouraged me 
to pray about my decision." 

The younger May had always knowTi 
that, like her father (and her mother, too), 
she would foUow a path of caring for the 
underserved. But it was not always clear 
to her that she would do so by pursuing a 
career in medicine. Growing up in Haiti 



in the storm.' His model of patient care — doing 
right reason — is the one I try most to emulate.'' 

until she was six, May was surrounded 
by adults, nearly aU of whom were med- 
ical professionals she admired. 

But as a child observing the demands 
placed on her father as the only surgeon 
on call for a large area, she knew that a 
doctor's life could be hard. Over the 
years. May thought about many different 
fields in which she might be of service, 
including public health and even the 
ministry. She took time off as an under- 
graduate to explore different experiences 
that included working as a home health 
aide. As an aide. May ended up befriend- 
ing one of her patients, a deeply spiritual 
man who had been rendered paraplegic 
in a motorcycle accident. Several days a 
week, she rose at five o'clock to arrive at 
the maris home and help him with basic 
physical tasks. The experience convinced 
her of her caUing to help people by minis- 
tering to their health. 

After HMS, which May chose in part 
because of its proximity to her parents, 
she considered returning to Haiti but 
was held back by issues of safety in 
that politically volatile nation. Like her 

father, she also knew that there were 
plenty of underserved communities 
right in her own backyard. And, as in her 
father's experience, providential circum- 
stances seemed to lead her to where she 
was needed. The same week that a fund- 
ing-contingent job May had lined up fell 
through, she happened to attend a lec- 
ture given by James O'ConneU '82, who 
runs the Boston Health Care for the 
Homeless Program. When O'ConneU 
offered her a job as a primary care physi- 
cian. May began a career providing care 
to people living in homeless shelters. 

May admits that, at times, the home- 
less can be a tough population to serve. 
"There are days when I don't feel Kke see- 
ing particular people. If a patient tries to 
dupe me by giving me false information 
on which I'm supposed to base clinical 
decisions, that can be discouraging. But I 
work hard at trying not to let previous 
experiences color my future treatment 
of people. I actually find it heartening 
that I stih get disappointed by patients 
at times, because this signals to me that 
I haven't become totally cynical." 

STREETWISE: An outreach worker chats with a client from the Boston Health Care 
for the Homeless Program, where Alison May serves as a physician. 

May relies on her faith to guide and 
sustain her — and on the lessons she 
learns from her patients. From picking 
up the latest street lingo to understand- 
ing how her patients find work or 
acquire drugs. May has received an eye- 
opening, practical education about 
ways of life entirely different from those 
found in mainstream populations. And 
yet. May says, she has had various 
patients speak to her about their faith 
as a sustaining force in their troubled 
lives — and not simply as a beacon to 
guide them to a better future. 

Despite their myriad problems, some 
of the homeless people with whom May 
works find a certain joy and inspiration 
in simply being alive in the moment. 
And some of the most valuable lessons 
these patients have to offer shed light 
on May's own behef system. "They teach 
me how I make assumptions about 
people, for example. I sometimes catch 
myself assuming that an alcohohc wiU 
keep drinking, but my experience has 
taught me that you can never count 
someone out. My patients remind me of 
this when I fail to remind myself." 

Powerful reminders of the right path to 
take come, too, from May's parents, who 
remain stalwart supports in their daugh- 
ter's Me. May has, on occasion, tapped 
into her father's rich legacy of compassion 
and chnical experience to sohcit guidance 
in dealing with difficult patient encoun- 
ters and in setting boundaries. "My father 
was always an 'island in the storm,'" says 
May "His model of patient care — doing 
the right thing for the right reason — is the 
one I try most to emulate. He has never 
been callous and has always been sincere 
in his desire to include and respect every- 
one. But he's never been shy about speak- 
ing out when things are going wrong. He 
may not be Mr. Nice all the time but he's 
definitely always Mr. Good." ■ 

Beverly Ballaro is associate editor of the 
Harvard Medical Alumni Bulletin. 




largely poor, immigrant patients in urgent care at the East Boston 
Neighborhood Health Center as "serving a slice of the developing 
world in the shadow of the big Boston teaching hospitals." For Hobbs, 
a Philadelphia native whose Quaker education exposed her early on to 
social justice issues and notions of the dignity of every person, serving 
the disenfranchised seemed a natural evolution of her career in emer- 
gency medicine. But there were other advantages as well, she discov- 
ered. Emergency medicine offered Hobbs the flexibility to raise three 
daughters, and also some of the most intriguing challenges to both her 
medical and social anthropology skills. 
"I was drawn to the field of emergency medicine," Hobbs says, 
z "because I find it fascinating to have that very first encounter with the 
° patient, unbiased by previous diagnoses and written records. I enjoy 
I the constant analysis and refinement of my own clinical acumen and 
i seeing my hypotheses tested as a diagnosis unfolds. To me, this is » 



the health and lives of vulnerable populations 


by Beverly Ballaro and Susan Cassidy 




medicine at its purest and most funda- 
mental level because I have to draw 
upon my communication skills, all five 
senses, and what I have come to call a 
'sixth sense' as well." 

Hobbs defines that crucial sixth 
sense as "a gestalt acquired over time by 
experienced clinicians," or a gradually 
internalized intuition for weighing the 
various data provided by the other five 
senses. "A real challenge of emergency 
medicine," she explains, "is to 
avoid premature closure." How- 
ever, she adds, the trained eye can 
pick up subtle visual clues at first 
glance from across the room to 
begin to formulate a diagnosis. A 
patient suffering from a kidney 
stone tends to writhe, sweat, and 
moan, while one with appendici- 
tis will likely be doing the 
"appendicitis shuffle" — bent over 
to the right and wincing in agony 
with each step that jolts that 
side. "Emergency physicians pride 
themselves in these across-the- 
room diagnostic hypotheses," 
Hobbs says. 

At other times, Hobbs has 
relied on her keen sense of smell 
to assist in a diagnosis. While 
alcohol is the most common and 
easily recognized odor, she 
points out that she routinely 
smells the breath of patients 
with diabetes or vomiting to 
detect the fruity scent of 
ketones well before confirma- 
tion by laboratory tests. When 
she once treated a young woman who 
had overdosed on an unknown sub- 
stance, Hobbs recognized the odd yet 
familiar odor on the patient's breath as 
similar to the insecticide that her 
father used on his rosebushes — 
malathion — and was able to begin 
specific antidote treatment prior to 
toxicologic confirmation. 

Working as she does in the vibrant- 
ly diverse community of East Boston, 
Hobbs has found that social anthro- 
pology insights can be just as crucial 
as medical knowledge in arriving at 
proper diagnoses. She recalls one case 
in which a 72-year-old Vietnamese 
man, accompanied by his son and 
grandson, came to the center after sev- 


eral days of abdominal pain and an 
inability to eat. Wincing but stoic 
whQe his belly was examined, the man 
insisted, through an interpreter, that 
the pain was minor. When Hobbs pro- 
posed her suspicion of appendicitis to 
the young surgical consultant, he was 
skeptical, on the basis that the maris 
right lower quadrant didn't seem par- 
ticularly tender to him. "This is where 
you learn the importance of placing 

THE SIXTH SENSE: Eleanor Hobbs enjoys the constant 
challenge of using skill and intuition to make quick, 
accurate diagnoses of her urgent care patients. 

the medical situation in the correct 
cultural context," Hobbs says. "I 
explained to my young colleague, 
'Look, I know from my two decades of 
working in emergency departments 
that you don't see a 72-year-old Viet- 
namese man dragged in by two gener- 
ations of his family unless he has a scri- 
ous problem.'" After tests confirmed 
that the patient did have appendicitis, 
the consultant thanked her for being 
alert to a cultural difference that he 
had not previously encountered. 

A Small World After All 

Yet the excitement of emergency medi- 
cine, Hobbs says, especially in the 

increasingly globalized world of urban 
community health, stems from the way 
it keeps all physicians, regardless of 
experience, on a continuous learning 
curve. Last year, the East Boston Health 
Center saw 4L000 patients in the adult 
urgent care department alone. Many of 
these were people who probably would 
have gone to hospital emergency 
departments were it not for the center's 
hard-earned reputation for dehvertng 
high-quality, culturally com- 
petent care. 

The center often serves as 
an important bellwether for 
health and demographic 
trends, Hobbs says. Like many 
of her physician colleagues, she 
is studying Spanish to help her 
communicate effectively with 
the majority of the center's 
urgent care patients, many 
of whom come from Central 
American countries. 

The global connections of 
the center's patient population 
bring particular medical chal- 
lenges. Every year, patients 
come in with tuberculosis and, 
nearly every spring, one or 
more El Salvadoran immi- 
grants are diagnosed with 
rubella. The prospect of a 
rapid spread of rubella among 
a young, fertile, and unimmu- 
nized El Salvadoran communi- 
ty is worrisome, Hobbs says. 
One year, just before Easter, 
health center physicians and 
the pubhc health department came up 
with the idea of ha\ang the priest in the 
local Cathohc church make a plea for 
free vaccinations during an Easter Sun- 
day Spanish-language Mass. This led to 
an enormous turnout at the immuniza- 
tion tables that health workers had set 
up in the church courtyard. 

"The best solutions to keep our 
patients well often arise from creative 
compromise," Hobbs says. She points 
out, for example, that 10 to 15 percent 
of the center's patients are Muslims, 
who fast during sunlight hours in the 
holy month of Ramadan. Working out 
a sensible way to manage diabetes dur- 
ing Ramadan is a challenge, for doc- 
tors and patients alike. 

"Cultural awareness is one thing, 
but as a medical doctor you have to 
draw the line somewhere," says 
Hobbs, who has dealt firsthand with 
ethical dilemmas created by cultural 
differences. For example, most of the 
center's Arab women patients wear 
the veil and come to the center accom- 
panied by a male relative. They gener- 
ally request a female clinician and 
chaperone. Hobbs and her staff ask 
the male relative to leave the room 
during the gynecological exam to pro- 
vide a safe opportunity to adhere to 
their "screen all patients" domestic 
violence policy. Senior clinicians also 
had to develop a response to an 
increasing number of requests for vir- 
ginity certifications. 

"While acknowledging that this is 
an important religious and cultural 
issue for some," Hobbs says, "we unani- 
mously felt that such certification is 
not a legitimate medical procedure, and 
that health care providers should not 
get involved." 

For Hobbs, navigating between var- 
ious cultures makes the work she does 
all the more professionally affirming. 
"It's not the same as going off to anoth- 
er country to experience international 
medicine," Hobbs says, "but it's about 
as close as I can get with a daily com- 
mute." She still works in the emer- 
gency department at Massachusetts 
General Hospital four to five times a 
month to keep her emergency skills 
sharp and up-to-date, and she derives 
great satisfaction from bringing that 
knowledge to her patients and peers 
at the health center. Although the 
challenges of practicing good medi- 
cine with limited funding can lead to a 
high rate of burnout among those who 
work in community health centers, 
Hobbs says she is likely stay in the 
same field until she retires. 

"I've worked with the educated, 
entitled, mainstream population, too," 
she says, "and that has its own set of 
challenges. Each physician has a dif- 
ferent calling, and the community 
health model has enriched my profes- 
sional and personal lives." ■ 

Beverly Ballaro is associate editor of the 
Harvard Medical Alumni Bulletin. 


city's most desperate people — a place, Stefan Kertesz '92 says, "where there 
is so much to care about, and the balance between the care one can offer and 
the care that is needed is painfully lopsided." In 1997, Kertesz took three and 
a half months, at his own expense, to volunteer at the hospital. In a facility 
where more than half of the patients die, many of tuberculosis or AIDS, 
Kertesz worked on a daily basis with terminally ill people he knew he 
would be unlikely to save. 

One such patient was a 17-year-old girl with AIDS. The hospital's nurses 
referred to her as an "abandoned housegirl," a young woman whose parents had 
left her to earn a living doing household chores for a family wealthier than her 
own. Kertesz and his colleagues surmised that she had likely been sexually vic- 
timized by a member of the family for which she worked. While Kertesz treated 
her medical condition to the best of his abihty, he wondered how a 17-year-old 
girl with AIDS, no family, and no job would ultimately fare. He points out that 
caring for people with so few resources requires a unique approach. "You ha\'e to 
imagine your way into a different world to understand what they face." 

Kertesz first imagined himself into this world when he \'isited Gabon in 
1992 on a Schweitzer fellowship and discovered his passion for providing care 
to underserved populations. "The reahty is that my 'altruism' is inextricably 

His patients have taught Stefan Kertesz valuable lessons 




bound up with what I like to do and 
what I am interested in," Kertesz 
explains. "My experience in Gabon was 
crucial in clarifying to myself that I 
found the process of care across bound- 
aries of culture and economic opportu- 
nity to be fascinating and rewarding." 

Part of what makes such work 
rewarding is the challenge of navigating 
the cultural and social issues that con- 
dition what treatments are available to 
any given patient. One of Kertesz's 
patients in Gabon, for example, was 
a woman displaying symptoms of 
depression. She was the second or third 
wife in a polygamous family and clearly 
not the favorite; she lived in a hut sepa- 
rate from her husband and his two pri- 
mary wives. Although Kertesz pre- 
scribed an antidepressant, he's not sure 
if it helped her, and he knows that 
much more than a prescription would 
have been needed to treat her condition 
effectively. Certain problems encoun- 
tered in developing countries are 
"almost unsolvable for a western-edu- 
cated medical student," Kertesz admits. 
"The well-intentioned outsider doesn't 
usually get to render a cure." 

But Kertesz is drawn to environ- 
ments in which much of his work cen- 
ters on identifying the barriers to pro- 
viding care and figuring out ways to 
work around them. "Over time," he says, 
"you learn to feel your way into patients' 
circumstances." And in some cases, it is 
possible to lessen a patient's pain, or at 
the very least, communicate to them 
that someone is there to acknowledge it. 

Currently a physician and faculty 
member at Boston Medical Center and a 
physician with the Boston Health Care 
for the Homeless Program, Kertesz sees 
many parallels between caring for 
impoverished patients in Africa and 
homeless patients in the United States. 
He gains from his interactions with 
them similar lessons and rewards. 
"Patients in so-called 'nontraditional 
settings' open up the imagination — to 
serve them we have to think more 
broadly" he says. "Minds are expanded 
and hearts are opened in the process." ■ 

Susan Cassidy is assistant editor of the 
Harvard Medical Alumni Bulletin. 



training and intuition bumps squarely up against a patient's deeply held 
cultural conviction? In her job as chnical director of the SeaMar Commu- 
nity Health Center near Seattle, EUen Rak '88 has found creatively nuanced 
solutions to balance professional obhgations with patient preferences. 

Once, Rak recalls, she was caring for a woman from the Oaxacan culture 
in Mexico. This patient had already deUvered several babies at home but 
had received prenatal care for her latest pregnancy through Rak's chnic. 
She planned to give birth in a hospital setting for the first time. The mod- 
est women of the Oaxacan culture, Rak knew, tend toward stoicism in 
labor and regard birth as an intensely private moment. Traditionally, they 
drape themselves with a sheet and squat on the ground to dehver. As Rak 
monitored her patient's labor, she noted with growing concern a pattern of 
decreases in the baby's heartbeat. Anxious to protect the health of the 
infant yet reluctant to trespass the bounds of the mother's informed con- 
sent, Rak suppressed her impulse to order the woman to get into bed. In 
the end, she and her patient settled on a compromise that respected the 
integrity of all involved: the woman dehvered a healthy baby from the tra- 

Ellen Rak has learned the fine balance between 

ditional squatting position — ^which she 
assumed in her hospital bed while the 
baby's heartbeat could stiU be monitored. 
Rak's interest in negotiating, in the 
role of physician, the dehcate spaces 
between different cultures arose from 
personal knowledge of the ways in 
which community support — or its 
lack — can affect people's chances of sur- 
viving and thriving. Family stories 
chronicling the hardships encountered 
by her grandparents when they emigrat- 
ed from Ireland and Czechoslovakia to 
New York City at the turn of the twenti- 
eth century sparked in Rak an early fas- 
cination with immigration issues and a 
special empathy for people entangled in 
them. "I always knew I wanted to be on 
the front lines, doing primary care, 
working in the real world," she says. "I 
was determined to use my education to 
help people who, like my grandparents, 
are 'strangers in a strange land."' 

Strangers in a Strange Land 

Although Seattle enjoys a reputation as 
one of the country's more affluent and 
cosmopohtan cities, the populations that 
Rak's clinic serves are a world removed 
from that mainstream urban culture. 
Most of the patients come from one of 
two disenfranchised groups: migrant 
farmworkers originally from Texas or 
Mexico, who setded in low-income hous- 
ing in the area after coming there to work 
in the fields; or rural poor people who 
took on low-paying jobs when Washing- 
ton's logging economy fell by the wayside. 

Rak acknowledges that many in the 
mainstream are distincdy uncomfortable 
with, if not hostile to, the patients she 
serves. "Unfortunately, some people tend 
to perceive migrant workers in terms of 
the problems they bring rather than the 
richness they contribute," she says. "And 
those people fail to see the beauty when 
connections to community are forged 
and success stories quiedy unfold." 

Rak has witnessed firsthand the com- 
plicated miseries that go hand in hand 

with poverty and sociohnguistic isola- 
tion. "My farmworker patients tend to 
present with advanced illnesses that 
have become serious over time from 
neglect," she says. "It is not uncommon 
for them to come to the clinic in extrem- 
is, suffering from out-of-control dia- 
betes, massive tumors, repetitive motion 
injuries, or debOitating depression." 

"On the other hand," she adds, "I've 
seen patients defy amazing odds." She 
recalls, in particular, one 15-year-old girl 
whose severely deformed joints resulted 
from juvenile rheumatoid arthritis. The 
girl's father had suffered a heart attack 
and her mother had cervical cancer. The 
family had no medical insurance at first 
but, bit by bit, they managed to move into 
the mainstteam of society. The girl had 
both knees and hips successfully replaced 
and is now thinking about attending law 
school. "That family had a real spark, and 
a wonderful work ethic," Rak says. 

Strong, extended family ties, Rak 
beheves, are one source of the richness of 
her patients' Mexican heritage. Another 
is spirituahty. The deeply held Christian 
faith of many of the migrant workers she 
sees in her practice anchors a philosoph- 
ical perspective on life — and death — not 
widely seen in mainstream American 
culture. One of Rak's early encounters 
with this philosophy came during her 
very first week on the job, when a young 
man came to her with a chronic cough. 
After steeling herself to break the news 
to him that he was infected with HIV, 
she was sttuck by his tempered reaction; 
"His first response was 'ni modo' which 
translates roughly along the lines of 'I 
can't control this. This is Me. It's okay 
and I need to move on.'" But, Rak adds, 
"his attitude was not one of resignation 
as much as it was a statement of behef in 
a higher divine plan. That kind of faith 
helps sustain many of my patients." 

Into the Mainstream 

Faith in the future, despite sometimes 
exhausting obstacles, is what helps sus- 

tain Rak, too, as she confronts the chal- 
lenges of what she describes as "hfe on 
the edge of the medical profession." 

"My road is very different from that of 
my colleagues in private practice," she 
says. "It's a constant struggle to practice 
tight, high-quahty medicine and meet 
all the audit guidelines. There is great 
pressure to work faster, even though 
many of the patients are both medically 
and psychologically complex." 

Despite all efforts, though, the drive 
for efficiency can sometimes lead to 
maddening catch-22 situations; nurses 
are often reluctant to use translation ser- 
vices because of their cost, Rak points 
out, but it can be even more expensive to 
miss a diagnosis the first time around 
because of a language barrier. To 
respond to such dilemmas, she has cho- 
sen to combine clinical with administra- 
tive work. "I hke to have a hand in the big 
picture," she says. "Tackling issues of 
organization and structure makes our 
jobs as clinicians easier." 

She remains passionate about her 
work despite its challenges. "It can be 
exhausting," says Rak, who balances 
work with the demands of raising two 
small children. "Frankly, I don't know ff 
I can do this forever. But it is also 
incredibly rewarding on a deep, person- 
al level to see so concretely the differ- 
ences you can make in people's lives by 
working within the community health 
care model." 

Ironically, Rak adds that her ultimate 
goal would be to eliminate the need for 
this very model, which has served her 
patients so well and brought her so 
much professional satisfaction. "I know 
it isn't common for people to wish that 
their jobs would become obsolete," she 
says, laughing. "But, ideally, I would love 
to see all of my patients make the transi- 
tion to the mainstream health care sys- 
tem and be able to access services 
designed to meet their needs." ■ 

Beverly Ballaro is associate editor of the 
Harvard Medical Alumni Bulletin. 

her own training as a doctor and her patients' traditional practices of healing 



Physicians find inspiration from traditional and unexpected sources 

Like Mother, Like Daughter 


■ y mother was "Dr. Gretchen 
Berggren of the Harvard 

, School of Public Health," as 
she often informed airline reserva- 
tion desks. We grew up in rural 
Haiti, where on a family outing we 
might see a mother of infant twins 
lying on the ground in front of her 
shack while her babies nursed in tan- 
dem. My mother would likely stop 
and encourage her "let maman scpli hon 
kr (mother's nulk is the best kind!). 
We might hear stories from Dad on 
why a man had pushed his way to the 
front of the market crowd waiting for 
immunizations: "Doc, you have to let 
me go first. I need to run home and 
give my pants to my brother so he can 
put them on and come and get his 
immunizations too." 

We would sing Creole songs by 
health educators on how to make 
oral rehydration solution from local 

products. We would stop and look at 
a cooking pot perched on three rocks 
over a charcoal fire on the ground. 
Besides remarking on the excellent 
protein content of the Haitian 
national dish of sos pwa, red beans 
and rice, Mom would admonish the 
cook to come back for her third 
tetanus immunization, pointing out, 
"If you took away one of the three 
rocks, the cooking pot would fall 
down, right? Well that's what can 
happen to your baby if you don't get 
all of your vaccines!" 

The annual Christmas pageant at 
Hopital Albert Schweitzer in Haiti 
takes place on a tennis court, with 
live donkeys and goats in the manger. 
At age five, I called out loudly during 
the pageant, "Who cut the umbilical 
cord?" "Hush," I was told, "it was 
probably Joseph, with a machete." 
The next question was logical and 
the obvious one to ask: "Why didn't 
baby Jesus get tetanus?" Why not 
indeed? It is a miracle that never 
seems to get discussed in church. 

Fast forward 30 years: I am "Dr. 
Ruth Berggren of UT Southwestern 
Medical School in Dallas," but my 
patients know me simply as "Docto- 
ra Ruth." They are Hispanic women 
with HIV, gay men, and injection 
drug users coinfected with hepatitis 
C. I try to teach about adherence to 
comphcated regimens. ("You know 
how that stool you are sitting on has 
three legs? What would happen if I 
cut off one of those legs on your 
stool? You'd have an unstable situa- 
tion there, right? Well, that's what 
will happen if you take only two of 
your three antiretroviral medica- 
tions.") Next I may counsel a woman 
with HIV who brings with her a 
healthy child, one who did not 
become infected with the virus. We 
wiU. remark upon this miracle, and 
talk about how to keep the child 
healthy. And so it continues. 


"Dr. Frank's political advocacy, 

data-driven research, and clinical 

impact bowled me over." 

Food for Thought 

In 1989, at the end of my sopho- 
more year of college, I stumbled 
into a small dinner at Harvard's 
Kennedy School of Government fea- 
turing a pediatrician named Debo- 
rah Frank [HMS '76]. As we gobbled 
down dinner. Dr. Frank began: "Do 
you realize that there are children 
starving in Boston tonight?" She 
then presented emergency depart- 
ment data showing that Boston kids 
were far more likely to have stunted 
growth during the winter months 
compared to the summer. "It's a clas- 
sic 'heat or eat' dilemma," she 

explained. The last part of her talk 
described her clinical work as part 
of a team devoted to nourishing at- 
risk children. Dr. Frank's political 
advocacy, data-driven research, and 
clinical impact bowled me over. Lit- 
tle did I know then that over the 
ensuing 15 years. Dr. Frank would 
help guide me in medical school, 
inspire me as a resident in her hospi- 
tal, and even introduce me to the 
rabbi (her husband) who would offi- 
ciate at my wedding. 


P K 4^ ^^ ' 

f '^^^'^^^^'^'B^^MB' i^^^M 

V" ■' ^Bygy^^^-i^i 

Ml. . 1l 


Twenty-nine days after our arrival 

all romance was shattered by 

Bob's accidental drowning." 

A Tragic Turning Point 

In late April 1982, I arrived in 
Lambarene, Gabon, to spend 
three months as a Schweitzer 
Fellow, working as a senior medical 
student at Albert Schweitzer's origi- 
nal hospital. Accompanied by my 
close friend and brilliant HMS class- 
mate Bob Ely, my anxiety about my 
rudimentary clinical skills was tem- 
pered by a deeply romantic excite- 
ment about all the "good" I might be 
able to offer to Africa. 

Twenty-nine days after our arrival, 
all romance was shattered by Bob's 
accidental drowning in the Ogooue 
River. In numerous eight-dollar-a- 
minute phone calls to family and 
HMS faculty about whether I should 
return home, I had to struggle deeply 
for the first time vvdth my real motiva- 

tions for traveling to Lambarene. I 
soon concluded that rurming home 
would forever confirm in my soul that 
my trip had most profoundly been a 
matter of comfortable. Ivy League 
noblesse oblige; staying would at 
least give me some hope of cormecting 
with, and perhaps beginning to 
strengthen, a different and deeper 
motivation for service. 

In words that Dr. Jonathan Mann 
later helped me understand, I arrived 
in Lambarene in a spirit of "charity" 
and left with the beginnings of a 
deeper sense of human "solidarity" — 
and of what Dr. Schweitzer called 
"The Fellowship of Those Who Bear 
the Mark of Pain." 


My mentor was Jesus 


Saving Face 

y earhest, and most influen- 
tial, mentor was Richard 
Stark, chief of the Plastic 
Surgery Department at St. Luke's- 
Roosevelt Hospital in New York City. 
One area in which Dr. Stark inspired 
me was his devotion to working with 
underserved populations. While I 
was a resident, I was aware of his fre- 
quent visits to Vietnam to perform 
surgery in a unit he had helped to 
found. The stories and photographs 
he brought back provided a "stark" 
contrast to the usual New York City 
patient population. Although I was 
not able to foUow his example at the 
time, later in my career I became 
involved with Operation Smile. I have 
since been on more than a dozen mis- 
sions in South America, the Philip- 
pines, Africa, and, most recently, 
Siberia. This summer, I will lead a 
team in Siberia. I encourage all physi- 
cians — particularly younger ones 
trained with and somewhat depen- 
dent on modern technology and infra- 
structure — to join one of the many 
groups tnvoh'ed in overseas volunteer 
activities. Not only do you perform a 
critical service for those less fortu- 
nate, but the confidence you gain 
from having to work with minimal 
technical support is invaluable — if a 
httle terrifying at first! 


A Head Start 

I have been blessed to have a 
number of people who, early on, 
provided the foundation for my 
career choice to help meet the needs 
of the poorest, least healthy, and 
most isolated members of our soci- 
ety through the National Health 
Service Corps. 

Christ, who spent the human segment of His life caring for all of humanity. 

George and Marie Weaver, my 
father and mother, continue to coun- 
sel and live the concept of including 
everyone, caring for the whole com- 
munity. From making sure that 
everyone on our Little League base- 
ball team had the chance to play (if 
they came to practice) to mobHiztng 
an entire elementary school to puU 
together for a spring activity, they 
reached out to ensure that everyone 
was included. Reaching out to the 
underserved is a logical extension of 
their Uving lesson. I cannot thank 
them often enough. 

Miss Rhoda Kain, my first-grade 
teacher, had a set of rules about 
grooming that had to be in place if 
you wanted to be selected to be a 
helper for the day. If you did not have 
yourself together, you were not 
afforded the privilege of helping oth- 
ers. While Miss Kain is no longer 
Mdth us, her message of making sure 
that you are appropriately prepared 
to accept the privilege of helping 
others hves on. 

Miss Mary Golden, my fourth- 
grade teacher, had a reading program 
that rewarded the student who read 
the most books for the year. She cre- 
ated a lust for learning and empha- 
sized to each student that anything 
is possible if you set your mind to it. 
I had the opportunity, a couple of 

months ago, to visit Miss Golden and 
thank her for farming the flames of 
pursuing possibilities. 

Upon reflection, choosing a career 
in the National Health Service Corps 
was set in a firm foundation of 
my early mentors' lessons; including 
everyone, preparing for the privilege 
to serve, and recognizing that any- 
thing is possible. I hope to reflect 
their caring, compassion, and com- 
mitment as the NHSC works to be an 
essential component of a health care 
system that assures access for every- 
one and eliminates health disparities. 


Lessons from the Frontlines 

As a hybrid product of Har- 
vard's MD-PhD program, I 
needed more than one men- 
tor. I've been blessed with many. 
Arthur Kleinman created a program 
that would permit several of us to 
train in both medicine and a social 
science relevant to medicine; his 
rigor and critical thinking has always 
inspired me. Jamie Maguire taught 
me so much about infectious disease 
and parasitology, the two areas of 
medicine that mattered most to me 
because these were the pathologies I 
saw in Haiti. Marshall Wolf '63 

helped me learn how to take care of 
patients and also how to cultivate 
vocation in physicians in training. 
Howard Hiatt '48 is more a friend 
than a mentor, but he made me 
believe that influence can be wielded 
responsibly — with outcomes that 
can serve the destitute sick. And 
then there are the patients, my great- 
est mentors: in Haiti and Peru and 
Boston, I have learned so much from 
seeing patients confront the linked 
problems of disease and poverty. 
Patients have been my greatest 
teachers, but I would never have met 
so many of them had the path not 
been cleared for me by the likes of 
Kleinman, Maguire, Wolf, and Hiatt. 
Harvard Medical School has been, 
for me, a mother lode of mentors — 
and I hope to give something back. 


Heaven Sent 

An early inspiration to practice 
medicine under difficult con- 
ditions came through contact 
with a surgeon who spent much of 
his professional life in Arabia. As a 
high school student, I was privileged 
to hear Dr. Paul Harrison talk about 
his experiences in taking modern 
medicine to folks who lived in a 


The real strength of Dr. Willis has been her personal devotion to the daily, unnoticed, and 

much less than modern society. He 
had so much fun and got so much 
satisfaction from doing this that I 
was inspired to do it myself. I didn't 
get to know him personally so he 
was not a mentor, but his experi- 
ences and his response to them were 
indeed an inspiration. 

A mentor, on the other hand, is 
someone whom one knows, admires, 
befriends, believes, respects, reveres, 
would hke to emulate, and, if possi- 
ble, would like to introduce to one's 
friends. As I spent my professional 
life working in rural Christian med- 
ical mission institutions, my mentor 
was Jesus Christ, who spent the 
human segment of His life caring for 
all of humanity but especially for the 
poor, the sick, the blind, the under- 
privileged, the rejected — the out- 
casts of society. I felt privileged to be 
able to try to do the same thing for 
poor villagers in a number of coun- 
tries, particularly Pakistan and 
China, while trying to emulate my 
mentor, who said that what one does 
for the poor, miserable folks in this 

world is done for Him. I am sure that 
Jesus enjoyed His role with these 
folks; I know that I did. 


Philosopher Kings 

I have had a wonderful time doing 
what I hke — caring for sick peo- 
ple, trying to be a good surgeon, 
and teaching. I have made unusual 
career changes, such as lea\Tng a busy 
surgical practice at age 50 and moving 
my tolerant wife and two small chil- 
dren to rural Haiti. Then later, when I 
was unable to fit into modern U.S. 
medicine, I fled to Appalachia. Who 
was my mentor? No one person, but 
through the "mystic chords of memo- 
ry," a phrase attributed to Abraham 
Lincoln, here is what I heard: 

The four maiden sisters of the 
Confederacy — Miss Ida, Miss Lulu, 
Miss Virginia, and Miss Mary — 
introduced me to formal schooling 
for the first four years in their one- 
room schoolhouse in rural Virginia. 
They influenced me by their kind- 
ness, fairness, and character. 

In taking the road less traveled, I 
was inspired by my immigrant father, 
who came to this country alone, at 
age 19. He became an ardent follower 
of Ralph Waldo Emerson and carried 
a book of his essays with him during 
his many long railroad trips. I have 
that same well-worn book on my 
bedside table. "Don't be afraid to be 
different," my father urged me. "Don't 
follow the herd." Much of his philos- 
ophy was Emerson's, which he passed 
on to me. I added Thoreau. 

Soon after coming to HMS, our 
class, while sitting in the original 
amphitheater of the Brigham, 
watched David Cheever do the first 

postoperative dressing on a patient 
who had had a radical mastectomy. I 
was immediately impressed by his 
courtesy and kindness to the patient, 
and by the gentleness of his hands. I 
saw much more of Dr. Cheever dur- 
ing my training, but that first experi- 
ence committed me: I wanted to be 
like him. Many others at HMS 
inspired me as well — ^Wilham Castle 
'21, for example, and a vibrant resi- 
dent staff at the Brigham, headed by 
J. Englebert Dumphy. 


Stamps of Approval 

Among the many mentors who 
have guided me, two in par- 
ticular stand out in my mind. 
When I first arrived at HMS, I was 
an older student, in my thirties. I felt 
that it made sense for me to focus on 
teaching and clinical medicine rather 
than research. But I also feared drift- 
ing away from the centers of excel- 
lence I had encountered at HMS. 
Dan Federman '53 had the enormous 
grace and vision to assure me of the 
legitimacy of my chosen path in med- 
icine: "Look outside our own door," 
he exhorted me. "You can do impor- 
tant and fulfilling work by providing 
excellent care to underserved people 
who hve in Harvard's shadows." 

In a similar vein, John Potts at 
Massachusetts General Hospital, 
although a hotshot researcher, made 
an early and strong commitment that 
the hospital's mission would include 
caring for vulnerable populations hv- 
ing nearby. When we first crossed 
paths, I had been thinking of becom- 
ing an oncologist, but Potts steered 
me to the Coahtion for the Homeless, 
a cormection that would eventually 


often unspectacular work. 

result in the Boston Health Care for 
the Homeless Program. Caregivers 
who work with people living on 
society's fringes sometimes risk 
becoming marginalized by the med- 
ical profession but Potts, like Dan 
Federman, has always offered me 
unwavering support of my mission. 


Above and Beyond 

When, as a high school stu- 
dent, I first heard Dr. Donoia 
Wilhs introduce her com- 
munity health program "Heart, Body, 
and Spirit," I was awed by the elo- 
quence and passion with which she 
discussed the importance of commu- 
nity service. My real inspiration, 
though, came later, as I watched her 
train lay volunteers in simple medical 
procedures into the early hours of the 
morning to accommodate their day 
jobs. I watched her coordinate elabo- 
rate health fairs, and then afterward 
drive community health workers to 
their homes. I appreciated her rous- 
ing speeches and innovative ideas, 
but marveled more at her patient 
counseling of health fair participants 
and commitment to overcome the 
obstacles inherent in any small-scale 
community health effort. Beyond all 
of her eloquence, accompHshments, 
and vision, the real strength of Dr. 
WiOis's community service message 
has been in her personal devotion to 
the daily, unnoticed, and often 
unspectacular work that powers any 
successful service project. My experi- 
ences with her over the course of sev- 
eral years have nurtured my interest 
in medicine and service work. 


i. « 



"It has been the dedication that 
she has exhibited in her crusade 
for educating disadvantaged youth. 

Aunt Glo 

When I reflect on all of the 
people who have had an 
impact on my life thus far, 
one very special person comes to 
mind. Her name is Gloria Singleton, 
and she has been more than a mentor. 
She has been a friend and an inspira- 
tion. Along with her husband, Alvin 
Singleton, she has dedicated her life to 
helping young people get an educa- 
tion who otherwise would not be able 
to afford it. The Singletons supported 
me through college, and have helped 
countless others. It has not been Glo- 
ria Singleton's philanthropy that has 
had the greatest impact on me, how- 

ever. It has been the dedication that 
she has exhibited in her crusade for 
educating disadvantaged youth, and 
the strength that she has most recent- 
ly shown in her battle with illness. 
She told me once that the one way I 
can pay her and her husband back for 
all they have done for me is to make 
sure I reach back and help someone 
else. Mrs. Singleton, or "Aunt Glo" as I 
have come to know her, has inspired 
me to give back to my community, and 
to be a servant and a teacher to those 
who need me most. 


In the golden years of their retirement, doctors discover that the spirit of volunteerism [ieldi 

Ui >^<: 



to realize that they wanted to do more with their retirement 
years than travel the globe as tourists. In the early 1980s, while 
teaching in Peru and Honduras under the auspices of CARE, 
they had discovered their mutual interest in working to 
improve the hves of poor people. Once back in the States, 
Zufall realized that there was clearly a need for clinic services 
in Dover, New Jersey, where he had maintained a private prac- 
tice in urology since 1954. The clinic could serve the city's 
large Latino population, the working poor in an area that 
Kathryn describes as "a pocket of poverty in a rich county." 


yields rich rewards for both recipient and donor 

by Susan Cassidy 



decades of working within a jj 
basic primary care. "Its likefl 

By the time he had retired in 1990, 
Zufall had taken the first steps 
toward founding the Dover Commu- 
nity Clinic, which began as something 
of a mom-and-pop operation. In 1991, 
the clinic became a nonprofit corpo- 
ration. A year later, the New Jersey 
Commissioner of Health visited the 
clinic, and its original $100,000 grant 
was increased to $235,000. Recently 
the clinic received a federal grant and 
was able to buy the building out of 
which it operates. 

Twenty doctors, all retired, volun- 
teer at the clinic, which pays for mal- 
practice insurance coverage for its vol- 
unteer physicians. These physicians 
treat between 10,000 and 12,000 walk- 
in patients per year; the clinic's dental 
program has 1,800 visits per year. 
Prospective patients undergo a finan- 

cial screening, and only those 200 per- 
cent below the federal poverty level — 
about $32,000 for a family of four — are 
accepted. They are asked for a small 
donation ranging from $5 to $40, 
depending on the services provided. 

The Learning Curve 

Running a community health clinic 
has been a learning experience for 
Zufall. After decades of working with- 
in a specialty, he has had to learn how 
to do basic primary care. "It's like 
being a family doctor," he says. "Colds, 
sore throats, diarrhea, aching backs." 
His wife jokingly refers to her hus- 
band as the "toenail king," in reference 
to one of the procedures that Zufall 
now performs regularly: surgery on 
ingrovvTi toenails. 

HELPING HANDS: "Volunteer doctors can't solve everyone's medical problems, but 
there's a definite need and a real place for them," says Kathryn Zufall (center). 

But the Zufalls' work involves more 
than just providing medical care. Many 
of the chnic's patients are members 
of a transient population — migrant 
workers who relocate frequently, hve 
with different relatives, and may even 
return to their home country for a 
while. Many of them may show up at 
the chnic only once every other year. 
This means that the volunteers must 
make the most of each visit, in terms of 
preventive education as well as med- 
ical care. While famOies are in the 
waiting room, children can participate 
in a reading program; the parents may 
be shown educational videos on diet, 
exercise, or dental care. The clinic has 
also hosted a program in Enghsh as a 
Second Language, run by teachers 
from a local vocational school. 

Such initiatives are a natural exten- 
sion of providing health care to under- 
served populations. Everything is 
interrelated — health, housing, employ- 
ment. Patients may need to be referred 
to social service agencies, job place- 
ment agencies, or schools where they 
can learn to speak Enghsh or develop 
other needed sldlls. The Zufalls seize 
every available opportunity to advo- 
cate for their patients and help them 
improve their hves. "When you see 
where many of these patients come 
from, and how hard they work, you 
realize how admirable they are." 
Robert Zufall says. "We're happy to be 
taking care of them." 

This doesn't mean that providing 
care is always easy. Some members of 
the population can be challenging: 
patients who are less than forthcoming 
about the details of their conditions, 
reluctant to comply with their doctor's 
directions, and not always appreciative 
of the care they receive. "Anyone who 



specialty, Zufall has had to learn how to do 
being a family doctor" he says. 

decides to care for the working poor 
knows that the patients aren't always 
going to be grateful, or gracious " says 
Kathryn. But, her husband adds, "We 
enjoy it. We really have a good time, 
even though there are challenges." 

The Zufalls are proud of the quahty 
of care they can offer their patients. 
Because there are usually two or three 
physicians at the chnic at one time, a 
patient who comes in with a problem 
can often get a quick consult right on 
the spot. Robert Zufall enjoys the col- 
laborative nature of the clinic, and 
describes the atmosphere as friendly 
and coUegial. But most of all, he empha- 
sizes how much fun he and his wife are 
having, despite the long hours and often 
challenging work. "We don't feel all that 
heroic," he says. "It's a job that someone 
should be doing, and we're doing it." 

A Sea of Red Tape 

In 1990, after retiriag to Boston from a 
distinguished career as an endocrinolo- 
gist at Baylor College of Medicine in 
Houston, Texas, James Field '51 also 
decided to volunteer his time to help 
people without access to adequate 
health care. But when he called the 
Massachusetts Medical Society to offer 
his services, they told him that they had 
no volunteer programs for retired 
physicians. Then they hung up. 

With so many uninsured and under- 
insured people in the Boston area, and 
so many retired physicians available to 
donate their time. Field found it hard to 
beheve that there was no program set 
up to link these two groups together. 
"Retired physicians have the experience 
and expertise, and patients certainly 
have the need for health care," he says. 
"It's a win-win situation for everyone." 

AAASTERS OF THE ART: James Field believes that older physicians are better than 
younger ones at conducting physical exams and taking patient histories. 

Field decided to try another 
approach: he called around to several 
shelters. Because he did not have a 
medical license in Massachusetts and 
was no longer covered by malpractice 
insurance, the shelters were unable to 
accept his help. And when he called 
other states and made inquiries about 
their programs, the response he got 
was, "We want to hear about yours." 

Eventually Field made some head- 
way. He called the Massachusetts Med- 
ical Society again, and the newly 
appointed executive director referred 

him to Leonard Morse, the society's 
president. Morse immediately saw the 
value of tapping into the expertise of 
retired physicians and set up the Com- 
mittee on Senior Volunteer Physicians 
(CSVP) to explore the idea, appointing 
Field as chairman. 

Despite great enthusiasm for the idea 
of retired physicians providing care to 
underserved, uninsured individuals in 
Massachusetts, the twin challenges of 
malpractice insurance and medical 
hcensing keep cropping up. "There are 
multiple levels of bureaucracy that have 




to be accommodated," Field says. The 
CSVP has been involved in several leg- 
islative attempts to resolve the malprac- 
tice and hcensure issue. Legislation to 
grant immunity to volunteer physi- 
cians, for example, was supported by 
organizations including the Massachu- 
setts League of Community Health 
Centers, the Massachusetts Coalition 
for the Homeless, and the Massachu- 
setts Medical Society. However, the 
Massachusetts Bar Association and 
Massachusetts Trial Lawyers Associa- 
tion testified against the bill. Although 
the bill was reported out favorably from 
the Combined House-Senate Health 
Care Committee, it was then referred 
to the House Ways and Means Com- 
mittee, where it was never acted upon. 

Another bill was introduced into the 
legislature that would develop a mech- 
anism to provide insurance to retired 
physicians volunteering free care. The 
bill proposed that funding for the 
insurance would be obtained by adding 
a small surcharge to the premiums paid 
by physicians insured by the Massa- 
chusetts Medical Professional Insur- 
ance Association. Again, the bUl was 
not acted upon by the Ways and Means 
Committee. Other legislative initiatives 
have also been stalled. "I think eventu- 
ally it will succeed, but I may not be 
around to see it," Field says. "It's very 
frustrating that it's taken so long." 

But Field and his colleagues haven't 
been relying on the legislative approach 
alone. The CSVP began negotiations 
with Promutual Insurance Company, 
which provides malpractice insurance 
for most Massachusetts physicians. The 
committee was successful in convincing 
the company to offer retired volunteer 
physicians a malpractice Uabihty poHcy 
for $500 per year, an 80 percent reduc- 

tion in the cost of their standard pohcy. 
The Massachusetts Medical Society has 
provided $12,500 for payment of the pre- 
miums as a pilot program. 

The committee also worked with the 
Board of Registration in Medicine to 
develop regulations for a special volun- 
teer license for retired physicians, 
which would have the same require- 
ments as a regular medical license but 
would be at no cost to the physicians. 
The license proposal still must be 
approved by the Department of Con- 
sumer Affairs and Business Regulation, 
and the State Committee on Adminis- 
tration and Finance. Finally, it would be 
subjected to the pubHc hearing process 
before final approval and implementa- 
tion. Field beheves that once a volunteer 
hcense has been estabhshed, there will 
be a significant increase in the number 
of retired physicians in Massachusetts 
who will volunteer. 

Southern Hospitality 

Although unable to see patients in 
Massachusetts, James Field has found 
a haven for his volunteer interests 
while taking a break from Boston's 
winter chill. During a stay of several 
months in Hilton Head, South Caroli- 
na, he volunteers weekly at the Volun- 
teers in Medicine (VIM) clinic, found- 
ed by Jack McConnell, who has been a 
pioneer in helping to establish 42 sim- 
ilar clinics nationwide. The VIM clinic 
offers free care to poor families living 
and working on Hilton Head Island. 

In South Carolina, a bill has been 
signed into law directing the South Car- 
olina Board of Medical Examiners to cre- 
ate a special volunteer hcense for volun- 
teer physicians from other states. The 
Joint Underwriters Association has 

Lo>v (center) and her young col- 
leagues see patients from Boston's 
Chinato>vn at the Sharewood Clinic. 

offered malpractice insurance to the 
VIM clinic, allowing physicians volun- 
teering their services to do so without 
individual malpractice coverage. The 
pohcy covers an unlimited number of 
doctors while they are on the premises. 
"As long as they're in the buUding, 
they're covered," Field explains. "As soon 
as they walk out the door, they're not." 

Field is adjusting well to the transi- 
tion from specialized medicine at an 
academic institution to seeing any 


helps you explore areas where you haven't been before," 
lolanda Low says. "It s a way to keep yourself alive." 

patients who walk through that door. 
Because of his background in endo- 
crinology, cases involving diabetes or 
endocrine diseases are often passed 
along to him. But a key aspect of volun- 
teering is venturing out into non-spe- 
cialty areas. "It's a much broader prac- 
tice," he explains. "I end up seeing cases 
that are not necessarily ia my area of 
expertise." hi addition to the learning 
curve. Field cites another positive aspect 
of working as a volunteer; "One tremen- 
dous advantage is that you don't have an 
HMO teUing you to see a patient every 
15 minutes. You can spend as much time 
with the patient as necessary." 

Pay It Forward 

While Field ended up traveling south to 
work as a volunteer, the CSVP has 
enjoyed a measure of success in helping 
15 retired physicians in Massachusetts 
find volunteer positions in community 
health centers and free chnics. One of 
those physicians is lolanda E. Low '53. 
Low's involvement with volunteering 
began at a party at the time of her retire- 
ment, when a Tufts professor urged her 
to teach first- and second-year medical 
students on a volunteer basis, teUing 
her simply, "We want you." Low 
beheves that working with students is 

important for retired physicians. 
"Teaching keeps you in contact with 
younger people," she says. "It's impor- 
tant not to lose that communication." 

Low had maintained her medical 
hcense, so she was also ehgible to volun- 
teer to tteat patients. Through the CSVP, 
she had learned about the Sharewood 
Free Health Chnic, which serves the res- 
idents of Boston's Chinatown and South 
End. Sharewood was established by 
medical students at Tufts University, 
and medical students from Harvard and 
Boston University come to help on a reg- 
ular basis. The clinic is held in a church 
basement on Tuesday evenings and pro- 
vides translation services in Mandarin 
and Cantonese to its patients. 

As soon as the legislature allowed the 
Massachusetts Medical Society to pro- 
vide low- cost limited malpractice 
insurance to retired volunteer physi- 
cians. Low began seeing patients at 
Sharewood in addition to teaching. 
"That's how I got lassoed in," she says, 
laughing. Although her specialty is 
infectious diseases, at Sharewood she 
sees any patients who walk through the 
door, with conditions ranging from sore 
throats to diabetes and hypertension. 

Once upon a time. Low jokes, she 
thought that instead of retiring, she 
would probably die with a stethoscope 
around her neck. Now, in retirement. 
Low stiU keeps her stethoscope close at 
hand. Clearly she finds her volunteer 
work rewarding, and she values the 
new ideas and experiences she is 
exposed to at Sharewood. "Volunteer- 
ing helps you explore areas where you 
haven't been before," she says. "It's a 
way to keep yourself ahve." ■ 

Susan Cassidy is assistant editor of the 
Harvard Medical Alumni Bulletin. 




by Carl Taylor 

. ^^%^.t■ 

second expedition to Nepal in 
1973, Cor! Taylor inspects his 
handiwork on a woman whose 
harelip he had repaired 25 
years eorlier, when the woman 
was an eight-year-old girl. 



of Natural History expedition that was 
given permission to collect birds and other 
specimens from the interior of Nepal. We 
were honored to be among the first foreign- 
ers allowed entry to a place described, at 
that time, as "The Most Closed Country in 
the World" and "The Last Home of Mystery" 

From October through December, 
members of our expedition hiked a 
transect from the Indian to Tibetan 
borders along the Kah Gandaki water- 
shed. I had taken along only a simple 
surgical kit — in case a member of the 
expedition needed an appendecto- 
my — as well as plenty of novocaine, 
iodine, and penicillin. Little did I sus- 
pect, when starting out on the expedi- 
tion, the significant role these rudi- 
mentary supplies would come to play 
during our journey. 

The Nepalese Government had made 
a request for a health survey Seeing 
patients along the route of our expedi- 
tion seemed the best way of gathering 
information on the country's disease 
burden. And, in the end, I did complete 
the first pubhshed health survey ever 
conducted in that country. But the peo- 
ple whose villages we passed through 
certainly would never have tolerated a 
laboratory-based, detailed study until I 
had created a rapport with them. So, 
over a period of three months, I ended 
up caring for more than 800 patients 
and did 57 operations, most of which 
were performed on people lying on 
stone fences and temple platforms. 

The first large town we came to after 
entering the country was Tansen. On 
my first day of seeing patients, the local 
mayor, or "Subha Sahib," as he was 
locally known, turned up with a large 
basal cell carcinoma of the right corner 
of his mouth. The Rana Governor Gen- 
eral, who ruled West Nepal, stated very 
clearly that he would not permit this 
valued official to travel to India for 

surgery. After extensive negotiations, 
the general finally said, "If you are not 
able to care for a simple sore on a maris 
face, then perhaps we should cancel 
permission for the expedition!" 

"Do something, please!" Bob Fleming, 
our expedition leader, urged me, as he 
envisioned our hard-won opportunity 
shpping away. When I objected that the 
necessary surgery performed under local 
anesthesia would simply be too painful 
to bear, the patient assured me, "A 
Nepali Gurkha can stand any pain." 
Yielding to that kind of pressure, I pro- 
ceeded to do a complete resection with 
the mayor stretched out on a temple 
platform and about half the population 
of Tansen as my eager audience. The 
mayor never flinched, and every time I 
cut a spurting artery, the crowd offered 
much enthusiastic advice. 

After I had sewn together the mus- 
cle layers for a somewhat puckered 
mouth and had placed the dressing, 
the mayor sat up and waved to the 
cheering crowd of spectators. I started 
to arrange a tent for postoperative 
care, but my patient shrugged off my 
preparations, telling me he intended 
to walk home. So I gave him a handful 
of codeine and aspirin and watched in 
amazement as he strode away. 

After that, it was difficult to refuse 
any procedure. Most of the expedition's 
porters eventually consisted of family 
members of patients waiting for surgery 
Some of the procedures they considered 
most dramatic took place on children. I 
operated on more than a dozen cases of 
burn contractures of the hand to free up 

small fingers that had been terribly 
scarred; curious babies, crawling around 
the mud floors of their dweUings, would 
sometimes pick up hve coals. I repaired 
an equal number of harehps, and also 
took care of a softball-sized bladder 
stone in one small boy. 

The effects of surgery struck many 
local observers as nearly magical. One 
day, people from a Baglung village in the 
middle hills watched in amazement as I 
made a single incision in the abdomen 
of a man who was unconscious and 
seemed nearly dead. To their horror, a 
stream of anchovy-paste pus spurted 
out 18 inches from a massive amebic 
hver abscess and fiUed two buckets. 
The next day, the patient was talking 
normally, eating, and sitting up; the day 
after that, he was back on his feet. 

Village folklore would later embell- 
ish the memory of the maris presurgical 
swollen abdomen as being doubly preg- 
nant in size. His family and friends had 
carried him for six days in a htter over 
mountain trails from his home \illage to 
seek my help. When I first saw him, I 
told his entourage that, tragically, the 
case was beyond any care I could pro- 
\'ide. But his friends retorted that they 
were not going to carry him six days 
back to his home, so I had better do 
something! It was obvious that incision 
and drainage was the only treatment 
possible, but very risky. It is perhaps not 
surprising that, on a return visit some 
50 years later, the original witnesses to 
that surgery, by now village elders, 
could stiU recall in \i\1d detail what had 
seemed to them a miracle. 

The Exotic and the Mundane 

The resilient spirit of many of the 
Nepalese patients we encountered on 
our 1949 expedition served them well 
in a rugged emoronment. The report of 
our first health survey documented 
health conditions in each region across 
the country and outlined the chal- 
lenges. Some diseases had rendered sur- 
prising beneficial effects. The notorious 
malaria of the pristine Terai Jungle, 


located just below the Himalayan 
foothills, had historically protected the 
Nepalese border with India from mOi' 
tary invasion, and helped keep the 
British at bay in the two Gurkha wars. 
Only the hardy Tharus, a jungle tribe 
with high resistance, were able to live 
in the inhospitable Terai. 

In most of the other areas we sur- 
veyed, we found more familiar and 
tragic patterns of Ulness. In the middle 
lulls, for example, diarrheal diseases 
dominated the clinical care. The lead- 
ing cause of death in children was 
diarrheal dehydration, as has been 
the case in all traditional societies 
throughout history. The cause of this 
widespread suffering was readily evi- 
dent, as we could smell a stream along 
the trail before we actually came to it. 
The Nepali practice of washing after 
defecation effectively contaminated all 
sources of water as latrine areas. In 
addition to the usual acute watery 
diarrhea, a significant percentage of 
people also suffered from chronic diar- 
rhea. And we saw many patients with 
enlarged, tender livers and the clinical 
symptoms of amebic dysentery. 

In the high mountain regions, people 
suffered from both diarrhea and com- 
mon respiratory diseases. Pneumonia 
was the second leading cause of death 
in children as, again, has been typical 
around the world and throughout 
history. The raspy sounds of chronic 
coughing punctuated the village nights, 
particularly from older people who had 
endured years of exposure to dense 
smoke from open fires in unventHated 
stone houses or thatch huts. Gurkha 
soldiers serving in the British Army had 
imported practices from the outside 
world such as cigarette smoking, which 
swept the country. The synergistic 
interaction of tobacco and heavy fire- 
place smoke exposure in homes had 
greatly aggravated the high prevalence 
of chronic obstructive pulmonary dis- 
ease and emphysema in the elderly. In 
addition to smoking-related illnesses, 
returning soldiers brought back sexu- 
ally transmitted diseases. 

an Taylor's First Trip to Nepa. 

first expedition to Nepal in 
1949, Carl Taylor and his 
colleagues entered the 
Nepal Terai on the backs 
of elephants. Highly trained 
hunting elephants such as 
this one proved invaluable 
in navigating the dense 
forests at the foothills of 
the Himalayas. The elephants 
v/ere capable of delicately 
retrieving with their massive 
trunks birds that had been 
shot and fallen to the 
forest floor. 

Local yak herders 
assisted members 
of Taylor's bird- 
collecting expedi- 
tion by guiding 
them to the habi- 
tats of several 
rare, high-altitude 
specimens of 
pheasants and 
quail. The yak 
calves pictured 
were prized 
for their milk, 
meat, and fur. 



Certain valleys harbored pockets 
of illness of a more exotic nature. In 
Pokhara Valley, we saw residual cases 
of an earlier encephalitis-like epidemic 
that frequently led to nerve deafness. In 
several places, asthma was almost epi- 
demic, and blood smears examined later 
revealed high rates of eosinophiiia. In 
one area, several children had bladder 
stones. And I gave the name "Lumpek 
Knee" to a severe arthritis that produced 
the massive exostoses of a classical 
Charcot's joint, due not to syphihs, but 
to the constant trauma of portering 
heavy loads down steep mountain trails. 

Silver and Gold 

Twenty-five years after the first jour- 
ney, we organized a repeat expedition 
with a peripatetic class of about two 
dozen American and Nepali medical 
students. At a police post near the 
entrance of the Kah Gandaki Gorge 
between Mounts Dhaulagiri and Ana- 
purna, I was surprised when officials 
had arranged for me to see a former 
patient whose harelip I had repaired 
during the original expedition, when 
she was just a child. The beaming 
woman brought along her happy fami- 
ly, which now included two children 
of her own. It gave me pause to consid- 
er that, had she not had surgery on a 
stone fence a quarter century earher, 
she would ha\'e had a bleak future; the 
local people considered physical 
anomahes such as a harelip evidence of 
the presence of an evil spirit. Tradi- 
tionally, the afflicted person would 
have been shunned and kept hidden in 
a dark room. 

When we organized yet another 
repeat expedition to Nepal in Novem- 
ber 1999, the main purpose was to doc- 
ument changes that had taken place in 
the environment and ecology, socioeco- 
nomic status, and health equity in the 
50 years since we had conducted the 
first study. Our only support, other than 
personal funds, was a small grant 
from the Rockefeller Foundation Health 
Equity Initiative. 

-^ "# ilii 

. ^ ;r:.' ■J:-'*!**^!'^-*!"? 'ftti**'^ 


The person who contributed most to 
the expedition was Bob Fleming, Jr., a 
leading Himalayan ornithologist and 
ecologist whose father had led the 1949 
expedition. But the genealogical con- 
nections didn't end there. The golden 
anniversary expedition was also a grat- 
ifying opportunity on a personal level. 
Three generations of my own family — 
myself, my two sons (including Henry 
Taylor 79), and six grandchildren rang- 
ing in age from eight to nineteen — 
trekked across Nepal. 

As we returned to familiar villages, we 
went down the Hsts of patients treated 50 
years earUer, and old-timers updated us 
on what had happened to most of them. 
Each of us chose a special project: Jesse, 
the oldest grandchild, did repeat photog- 
raphy to document ecologic change (he is 
the second youngest author ever to have 
an article appear in National Geographic): 
Chris followed the trek by running 
across Nepal in five and a half days; Luke 
studied butterfly density; Ruth investi- 
gated the nutritional status of children; 
and Caleb and Anna examined the 
games and toys of Nepah children. 

The passage of time, we discovered 
on our 1999 expedition, has had 
mixed blessings for Nepal. In the 50 
years since we began tracking health 
conditions there, Nepal has probably 
been more overrun by foreigners than 
almost any other developing country, 
thanks to the beauty of its environ- 
ment, its amazing people and culture, 
and the adventure potential of having 
the highest mountains in the world. 
The outsiders have included foreign 
aid agencies trying to improve health 
and socioeconomic conditions. 

Mortahty decline due to socioeco- 
nomic development and basic pubHc 
health programs has reduced deaths by 
about half. This has contributed to the 
almost tripling of human population in 
the past 50 years, and population 
growth now dominates all aspects of 
development. But these gains have not 
been made without cost or conse- 
quence. In the Terai, what were once the 
world's most exciting jungles have been 
almost totally wiped out, mainly 
because of malaria control with DDT 
since the 1950s. The jungles have been 

PARADISE LOST: Local residents 
>vashing clothes on the shore of a 
then-pristine lake in Pokharo in 1949. 

replaced by rice fields that are tem- 
porarily feeding the growing popula- 
tion. Yet food equity remains in severe 
jeopardy; our surveys found that half of 
the families in the middle hills, where 
most Nepahs hve, run out of food stored 
in homes for three to six months of the 
year and are reduced to subsistence hv- 
ing off of daily wages as porters or in the 
Terai. The women and children make do 
as they can back in the villages. 

Government health services in Nepal 
provide the anatomy of a health system, 
but one with minimal functioning phys- 
iology. Although all facilities were 
designed as a unified government health 
system to be supported by pubhc fund- 
ing, that has been steadily shrinking 
because of the economic adjustment 
pohcies of the World Bank and Interna- 
tional Monetary Fund. Almost all pubhc 
funds go into salaries, which have not 
been raised for many years, and essen- 
tially nothing is left over for medications 



or any other support for health facilities. 
Better quahty services in both private and 
government hospitals and expanding spe- 
cialty services are increasingly available in 
towns and bazaars. 

As in most poor countries, care is paid 
for through booming privatization, 
which creates massive problems of access 
for the poor. Globalization of pharmaceu- 
tical sales dominates acute medical care. 
Uncontrolled sales in flourishing "medi- 
cine shops" have become the main source 
of income for health staff. Government 
health posts have few medicines but, typ- 
ically, the medicine shop next door — run 
by the family of the health assistant — 
stocks all the popular drugs. 

Public health services have tended not 
to be sustainable when they have used ver- 
tical campaigns. The exception seems to 
be the UNICEF program in the 1970s that 

installed plastic pipes for bringing water 
into villages, so that safe water now reach- 
es most homes. Immunization of children 
is still available for families who take the 
initiative of going to health posts, but out- 
reach is Hmited to national immunization 
days aimed at eradicating poHo. People 
prefer oral drops to injections, and Htde is 
done to convince mothers that they still 
need to bring in their babies for other 
shots. A mass program for the semiannual 
distribution of vitamin A drops to children 
under five is slated to achieve national cov- 
erage. A Johns Hopkins field research team 
based in the Terai under Alfred Sommer 
'67 has demonstrated remarkable maternal 
and child mortality reduction. 

Female community health volunteers 
(FCHVs) represent the main hope for 
services for the poor, and for women 
and children. Systematic community 

empowerment is needed to help the 
46,000 FCHVs who now work in all the 
major villages. They do social mobiliza- 
tion for services such as family planning 
and oral rehydration and are the main 
mobilizing force that maintains public 
health coverage in poho eradication and 
vitamin A distribution. But they receive 
little formal support or recognition 
from health posts, village development 
committees, or the polio eradication 
program. Their main support is from 
the vitamin A program. A systematic 
building of their capacity would ener- 
gize the whole health infrastructure. 
Decentralization and scaling-up of suc- 
cessful demonstration projects could 
promote effective, community-based 
primary health care. 

The FCHVs were blunt in describing 
the sacrifices their work imposes on 

Home Schooling hy Henry Taylor 

developing nation like Nepal has much of value 
to gain from — and to teach — the West about 
health equity. When I accompanied my father 
on his repeat expedition to Nepal 50 years after 
he published his first health survey of that coun- 
try, I could not help but be struck by a number of 
historic parallels between conditions there and 
here In West Virginia, where I am state health commissioner. 

Indeed, morbidity patterns in West Virginia 100 years ago were 
quite similar to those seen in Nepal at the time of my father's first 
health survey in 1 949. Records from 1 893 show that the single great- 
est cause of death in West Virginia was diphtheria. In 1 896, it was 
cholera infantum, a diagnostic label for all infantile diarrheas. Yet dur- 
ing the decade of the 1930s, West Virginia went on to receive recog- 
nition as a leader in U.S. rural health care thanks to the construction, 
in a ten-year period, of 300,000 pit privies, which greatly alleviated 
the kinds of sanitation problems with which Nepal has also struggled. 
Both West Virginia and Nepal, despite their enormous differences 
In health status and resources, continue to wrestle with the challenge 
of providing clean drinking water to their citizens. Plastic pipes can 
get the job done In Nepali villages, but towns remain In need of 
more permanent and expensive systems. In West Virginia, a revolving 
loan fund, which will eventually total more than $68 million from state 
and federal sources, is currently being used to expand small public 

water systems and reduce the need for Isolated homes to drill wells or 
collect rain or surface water. 

While both areas are blessed with abundant surface waters flowing 
down steep mountain valleys, rapid industrial development is putting 
pressure on governmental agencies in West Virginia to relax the envi- 
ronmental standards Imposed by the Clean Water Act and the Safe 
Drinking Water Act of the 1 970s. All water In West Virginia is currently 
deemed drinkable, meaning industries must adequately treat their dis- 
charge before It enters a stream, except In limited areas. Yet the chemi- 
cal and manufacturing Industries want to shift the burden of protection, 
so they can discharge waste Into streams unless testing documents 
unacceptable levels at the Intakes of public water systems. Recently, the 
governor Issued an executive order empowering me as state health 
commissioner to Issue "fish consumption advisories" against eating cer- 
tain fish taken from specific areas. Clearly, the United States is strug- 
gling to balance a toxic lifestyle and the natural environment. 

Malaria remained a problem in West Virginia until control mea- 
sures after World War II reduced mosquito breeding. More recently, 
the state had to reinstitute mosquito control programs due to massive 
mosquito breeding in scrap tire piles. The black rubber warms rain 
water and thus creates an excellent habitat for mosquito vectors of 
LaCrosse encephalitis and, potentially. West Nile virus. 

West Virginia Is the second most rural state In the United States, 
with the highest median age and the lowest median Income. Its citi- 


their families. A typical focus group 
was in Lumpek, north of Tansen, 
reached by a vertical climb of more 
than 5,000 feet. Fifteen women were 
attending a training session for vita- 
min A distribution. Some said they 
had awoken before dawn and walked 
for three hours to get there. With 
much passion, they told us that they 
have to be available for 24'hour work- 
days when the polio and vitamin A 
campaigns take place twice a year. 

"When we get home," one of the 
women told me, "the cows, buffaloes, 
and pigs are all hungry, the children 
are crying, and our husbands are 
unhappy because the food is not 
cooked. We get very little support 
from the health post or the village 
development committees; all they give 
us is orders." 

When asked why they continue this 
volunteer work, the FCHVs shouted 
their response. Their neighbors wouldn't 
let them resign, they told us, because 
the children's health depends on them. 
Their neighbors further criticize them, 
because they assume the women are 
making a profit from their hard work. 
The women have almost no medicines 
or supphes, so they are supposed to 
charge for medicines in order to pur- 
chase their next supplies, but the poor 
people cannot afford even minimal 
expenditures. Yet Lumpek's dropout 
rate was typical of that in aU villages; 
out of the fifteen women who started 
training six years ago, only two have 
resigned and been replaced. 

Sustainable health progress will 
require health equity to become a prior- 
ity government objective. Nepal is a case 

study of the reahty, which the United 
States also needs to accept, that health 
care must include essential services for 
the poor and neglected, not just private 
services for families with resources. In 
Nepal, diseases are concentrated among 
the poor, who, when desperately iU, 
take out high-interest loans at medicine 
shops. The resulting spiral of debt is a 
major reason for the nation's continuing 
poverty. Health conditions will not 
improve until priority public health 
programs reach these families. Unfor- 
tunately, such programs have essential- 
ly collapsed in both Nepal and the 
United States. ■ 

Cad Taylor '41 is professor emeritus of 
international health in the Department of 
International Health at the Johns Hopkins 
School of Public Health. 

zens have a growing need for medical care but face difficult barriers. 
Since the 1 940s, the leading cause of death in the state has been car- 
diovascular and other chronic lifestyle-related diseases, as is also true 
of affluent families in Nepal. The state legislature developed a network 
of community-based primary care centers in medically underserved 
areas in the 1 970s and 1 980s. Now there are more than 1 00 com- 
munity-run practice sites in the most inaccessible areas, one of the 
largest number of any state, and certainly the highest per capita. 

Small towns in West Virginia have faced great difficulty in recruit- 
ing and retaining primary care providers to replace the disappearing 
country doctors who had served so well for so long. Along with the 
development of community-run health centers, the state has begun pro- 
grams to attract a new breed of "modern" country doctors and essen- 
tial specialists in obstetrics, pediatrics, and surgery. In fact, I became 
a West Virginian "by choice" through the National Health Service 
Corps by developing a community health center in a sparsely populat- 
ed area to practice internal medicine without a hospital. 

As in Nepal, pilot projects prove the efficacy of lay workers in com- 
munity health, especially in the area of prenatal and early childhood 
core for the growing numbers of people with no health care coverage. 
Without ongoing state or federal reimbursement, these efforts hove never 
gone to scale. In a small network of faith-based practices, community 
members do health education and support. An overwhelming expansion 
of Volunteer Rescue Squads provides essential emergency services to 

small communities. Some businesses are seeing a measurable return on 
investment from employee-run worksite wellness programs. Other projects 
ore exploring the provision of diabetic care through a Medicaid waiver, 
and systematic coverage of tobacco cessation products and counseling. 

The greatest challenge for the future, in both Nepal and West Vir- 
ginia, is health equity, or health core for the poorest and most needy. 
Equity is a fundamental value for all health core systems and a prima- 
ry determinant of sustainable health development. Reviewing health 
system and health status changes over 50 or more years highlights 
important trends in equity, trends that get blurred by the chaos and 
commercialization of day-to-day health core delivery. 

In Nepal, the immediate need is for a community support system for 
female community health volunteers. As a result of my father's surveys, 
donors have started a systematic effort to develop support mechanisms 
for them. In West Virginia, internal complexities and competing private 
and public interests make workable solutions more uncertain and diffi- 
cult. Political pressures moke it necessary to gain public support for 
preventive programs. Grassroots efforts by empowered community 
action groups, but shepherded by governmental agencies and experts, 
seem to be the most cost-effective way to infuse equity into society and, 
especially, into our respective health core systems. ■ 

Henry Taylor '79 is commissioner of the West Virginia Bureau for 
Public Health. 

SPRING 2001 



^'■&r ' 

\ !^sV-^- 


several hours in a van, winding through the mountains, past two mihtary checkpoints and ^ 

several towns. Finally I stepped out onto a dirt road leading off the highway. In my backpack ; 

was a list of tuberculosis patients from the highlands of Chiapas from the past six months; \ 

in my right hand was an ice-filled cooler for the sputum samples of patients with a produc- * 

tive cough — those who were being cured, those who had relapsed, those who could not be - 

cured. My accouterments reminded me of my mission here: to discover what had happened f 

to these patients, indigenous people living in great poverty in the countryside. :; 

As I walked along the path through the green, rolling hills, breathing the fresh, cold air s 

filled with the aroma of vegetation, I already knew the limitations of my mission. Now 2 

toward the end of my nine-week summer research project, it was clear that the sheer mis- : 

ery of the indigenous people living here was so great that the help I could offer was usually i 




Kr l-i^. 

A medical student sheds light on the 
larsh realities of life — and death — for 
indigenous people with tuberculosis 
in the highlands of Chiapas, Mexico 

by Anna Flattau 

TRAGIC CYCLE: A refugee 
camp in Polho, Chiapas 
(above). A large portion 
of the population who live 
here are children; they are 
basically healthy, but as 
time passes many develop 
tuberculosis. Right: A man 
from a shantytov\^n on the 
edge of San Cristobal lies 
dying of tuberculosis in 
a local hospital. 


t was clear that the sheer misery of the indigenous 
was so great that the help I could offer was usually 

Pacific Ocean 

too little, too late. I recorded the stories they told me 
about their illnesses in my notebook, and although I 
might repeat in my voice what they had told me in theirs, 
the fruits of my labor were unlikely to bear them succor. 
By the time I could pass on the stories of their suffering, 
many would have died. 

I was fortunate this day, because the men in the first 
house I approached led me to the woman I was seeking. 
They spoke no Spanish, but with her name and the 
indigenous word for "tuberculo- 
sis," I made myself understood. I 
followed them to the yard out- 
side her hut, whose dirt walls 
were topped by a thatched roof. 
They spoke briefly with her hus- 
band who, like them, wore a 
knee-length white tunic belted 
at the waist. Children stood 
watching me; a dog barked furi- 
ously. The men beckoned me 
inside while a boy ran to find 
someone to translate. 

In the one-room hut, I saw 
Dona Rosa curled on her side, 
wrapped in a worn blanket on a 
bed of naked boards. From my list of patients, I knew 
that she was 29 years old and had been diagnosed with 
tuberculosis at a government health clinic six months 
before. She was clearly nearing death: her face had been 
transformed into the wasted, ageless mask of tuberculo- 
sis, and her limbs were bone-thin. She moaned softly, and 
her quick, shallow breaths rattled through clogged air- 
ways. From time to time, she put her fingers to her mouth 
and extracted gobs of phlegm, which she dropped onto 
the floor. 

I feared that my words would be inadequate to 
describe the gravity of her situation to the doctors at the 
hospital in San Cristobal, the main city of the highlands. 
I was a first-year medical student who had not yet 
learned to perform a physical examination. It occurred to 
me to count her respirations: 40 breaths per minute, I 
diligently wrote in my notebook. 

Over the next week, I returned twice to this village. I 
learned that after diagnosing her with tuberculosis, the 
clinic workers had given Dona Rosa antibiotics. She took 
them for a time, but when she ran out, her husband did 
not make the necessary three-hour walk through the 



Gulf of Mexii 

mountains to the clinic. She had not improved, and the 
pills had given her a burning sensation in her stomach. A 
village official confirmed that there was little food in her 
house: she had taken the medication into her malnour- 
ished body on a near- empty stomach. I offered to have the 
Red Cross ambulance drive her to the hospital. After 
deliberating overnight, her family decided that she 
should stay at home. In the hospital, they said, people are 
more likely to die; and in any case they had not a single 
centavo to pay for medications 
or the expenses of family mem- 
bers who would accompany her 
to the city. Although I said I 
could help, they decided that if 
she was to die, it would be better 
for her to do so at home. 

I asked if others in the area 
had the same disease. Dona 
Rosa's family mentioned several, 
at least one of whom was also 
nearing death. Their homes were 
scattered in the mountains, and 
there were no paths. I tried to 
have the village officials deliver 
containers to their houses so I 
could collect the sputum samples on a subsequent visit, 
but the containers never reached the houses, and I came 
back empty-handed. The following week I returned to 
the States. 

Uncivil War 

Chiapas Region 

Dona Rosa was one of 44 people with tuberculosis 
whom I sought out and interviewed about their course 
of illness. All were listed in the health district's reg- 
istries of tuberculosis patients as having been diagnosed 
or having submitted a sputum sample within the previ- 
ous six months. Of these patients, eighteen were "sick," 
defined as continuing to have a chronic productive 
cough or having had a recent positive sputum smear, 
despite treatment. Three of the patients were dead. Six- 
teen were "well" — that is, they had completed at least 
three months of treatment for tuberculosis, or had aban- 
doned treatment, yet no longer had a chronic productive 
cough or a positive sputum sample. Five had completed 
fewer than three months of treatment and were contin- 
uing to take the medication, so their outcome was not 

people living here 
too little, too late. 


yet certain; two did not give adequate information about 
their current state of fiealth. 

In addition to these patients, I spoke with 19 people 
not on the original list — chronic coughers pointed out to 
me by local clinic staff or community members, or family 
members of the patients. All in all, I interviewed 63 peo- 
ple with tuberculosis in 32 different villages in 13 munic- 
ipalities of Chiapas. 

Dona Rosa's story was not unique. The highways lead- 
ing out from San Cristobal were dotted with the villages 
of other patients I had visited, many of whom had also 
received suboptimal treatment. One of the first patients I 
visited was a pregnant mother who lived a three-minute 
walk from the local clinic. She was attending the clinic 
regularly for prenatal visits for her baby, who was due that 
month. Yet she was not being treated for a relapse of tuber- 
culosis so severe that she looked skeletal. She slumped in a 
chair with her head lolling to one side as she told me that 
she could no longer sleep because of constant coughing. 

The clinic had sent two sputum samples to the hospi- 
tal laboratory, but because the smears had been read as 
negative, her case had been dropped. I insisted that the 
local clinic doctor examine her, but, surreally, it seemed as 
if the doctor and her assistant were oblivious to the fact 
that the woman was dying. They said that she did not 
respond well to her first treatment because she was mal- 
nourished. I paid the bus fare for the woman to go to the 
hospital, where an x-ray showed that her lungs had been 
largely destroyed by the disease. The last I heard, her baby 
had been born. Soon afterward, she checked into the hos- 
pital because she had begun to cough copious blood, and 
it had not stopped for three days. 

Epidemic of Injustice 

Chiapas is best known abroad because of the armed 
indigenous uprising in 1994 by the Zapatistas, who 
include adequate health care among their demands on 
the government. Further media coverage about the 
region followed as a result of episodes of violence and 
government-backed atrocities. Most recently, the possi- 
bility of renewed negotiations with the government and 
the arrival of the Zapatista leadership in the Mexican 
capital have made international news. 

This conflict between the Zapatistas and the govern- 
ment is best understood when viewed against the back- 
drop of daily life in the region — the desperation of the 


.^^■•■^ ?-^ 


■ wttiltSt,^ 

GRIM TOLL: A man awaits treatment for tuberculosis in 
a clinic in Chiapas, Mexico. His wife's tuberculosis >vas 
cured a dozen years ago; their daughter is receiving 
treatment and their son was recently diagnosed. 

indigenous population's situation, so grave that some 
were willing to lose their lives in the hopes of improving 
their people's lot. The purpose of the uprising was, pre- 
sumably, to call attention to the everyday atrocity of leav- 
ing people to suffer hunger and sickness because of their 
status as second-class citizens. The gun battles, machete 
attacks, and political speeches have been given more 
attention, however, than the profound suffering that 
slowly and silently unravels in Chiapas every day. 

After several weeks there, I began to find the soldiers 
who dotted the highways less disturbing than the doc- 
tors who, despite their professional and moral mandate 
to save lives, seemed not to care for their patients. The 
soldiers were trained to carry guns; they would shoot 
people if so instructed, but could be withdrawn from the 
region — as reportedly they have been — with a single 
order. The poor quality of health care for indigenous peo- 
ple, however, is more insidious. Like many other deep- 
rooted injustices, it will be harder to change. 

In many of the cases I saw, the Mexican health ser- 
vice's mandate to treat and control tuberculosis did not 
seem to apply to indigenous people in Chiapas. Certainly 


fter several weeks, I began to find the soldiers 
who, despite their professional and moral 


more have suffered, been disabled, and died from lack of 
treatment for this disease alone than from gunshots. 
When I witnessed the insufficient medical care some of 
these patients received, it seemed to me to be a form of 
violence as well. 

After spending some time in the clinics, I understood 
why people often waited until they were direly ill before 
approaching a doctor. Patients who barely understood 
Spanish were quickly shouted instructions that they 
often could not comprehend. People who arrived in the 
clinic in pain languished in the waiting room while, 
within their earshot, the medical staff sat idly, chatting 
among themselves and laughing. One doctor banged 
ceaselessly on a gigantic manual typewriter while inter- 
viewing his patients, intimidating them greatly. Often 
there were no medications — and no indication to the 
patients whether the drugs would ever arrive. One doc- 
tor told me that, upon arriving at a clinic one afternoon, 
she had found a corpse stretched out in front of the clin- 
ic doors. Office hours had ended, and the staff had forced 
the man to leave because their shift was over. Desperate- 
ly ill, he had simply died there. 

Forgotten Souls 

Insufficient care for tuberculosis patients was not limit- 
ed to rural clinics. Of the patients who had been diag- 
nosed with tuberculosis by the health district's laborato- 
ry in the previous six months, two had never learned of 
their diagnosis. Their names had been listed in the labo- 
ratory's diagnostic book, yet the doctor in charge of 
tuberculosis control had neglected to transfer their 
names to her log and initiate treatment. 

The first such case I uncovered was that of Don Luis, 
an elderly man who lived in a muddy street of the small 
city of Villa las Rosas. His sputum sample had been read 
in the laboratory as positive for tuberculosis five months 
before my visit to his home. After speaking with his wife, 
I returned the next day to see him; he had given up a day 
of work to speak with me, no small sacrifice for a peasant 
day laborer who barely subsisted off his daily earnings. 
Don Luis had first become ill a year ago, and went to the 
government clinic, where he received short-course 
antibiotics that did not cure him. Subsequently he had a 
severe attack of fever and weakness, and he coughed 
blood profusely. He was treated by a local healer and then 
by a private doctor in the neighborhood, who neither 
cured him nor tested him for tuberculosis. The third time 


UNCERTAIN VIGIL: A woman sits in the 'waiting room 
of a hospital in Chiapas, Mexico. 

he began to cough blood, very HI and afraid of dying, he 
returned to the government clinic, where he was asked to 
give sputum samples to be tested for tuberculosis. 

When Don Luis returned to the clinic two weeks later 
to collect the results, he was told that one sample was 
lost and the others would not have results for several 
more weeks. He left in anger, feehng that the health ser- 
vices had abandoned him to die. The positive test results 
were never communicated to the clinic in his city, so no 
one followed up on his illness. The only relief he had 
received for his symptoms was a tea made of leaves from 
a local bush, which he took on a neighbor's advice. He 

who dotted the highways less disturbing than the doctors 
mandate to save hves, seemed not to care for their patients. 

had managed to recover from his latest crisis and was 
now able to work again, despite his constant productive 
cough. He feared, however, that he would relapse. 

After discovering the case of Don Luis, I found a sec- 
ond person whose name appeared in the laboratory 
record but not in the treatment registry. A colleague and 
I visited the home of Don Cristobal in Chacamuc, 
Oxchuc, an area of semitropical forest. After two hours 
on the highway, we walked an hour and a half along a 
wide dirt road to the first houses of his village. From 
there, with the help of directions from villagers whom we 
encountered along the road, we found Don Cristobal and 
his wife working in their cornfields. It was beginning to 
grow dark, and we followed the couple to their house in 
a sudden thunderstorm, covering ourselves in the pon- 
chos that our hosts insisted we take. After perhaps two 
hours along a tortuous, muddy path through the jungle, 
we arrived at last at their small wooden shack. There we 
spoke to Don Cristobal, ate with his family, and spent the 
night as his guests before returning to the main city the 
following morning. 

Like Don Luis, Don Cristobal had gone to the govern- 
ment clinic when he became ill. Wasted and weak with 
tuberculosis, unable to carry on with the subsistence 
farming that provided food for himself and his family, he 
undertook the long walk to a clinic located along the 
highway, where he gave sputum samples. On the appoint- 
ed day two weeks later, he returned, only to be told that 
there were not yet any results. Fifteen days and another 
journey later, again there were no results. Feverish, skele- 
tal, and coughing blood, Don Cristobal felt he was going 
to die. He paid the bus fare to go to the nongovernmental 
hospital in Altamirano, where he was hospitalized for 
two weeks. He continued his treatment and was cured, 
but his travel expenses landed him in a debt he was 
unlikely to be able to repay. 

Life After Death 

My original list of tuberculosis patients contained 136 
names; of these, I had time during my stay to seek out 
only 56 patients, most of whom I found. There was the 
woman in Chamula whom the doctors already knew had 
multidrug-resistant tuberculosis, and whom they no 
longer knew how to treat. There was the all-female 
household in the remote, low-lying, tropical village of 
Amaquil in Tenejapa, whose sole male relative had died of 
tuberculosis two months ago. He passed away while tak- 

ing his second course of treatment from doctors who, 
according to his paperwork, were not aware that he had 
already been treated. 

The neighbors told me about someone else who was 
not on my list: an old man in the same village. When we 
visited him, he cried as he told us that he was too weak 
to walk to the clinic to replenish his supply of anti-tuber- 
culosis drugs. He knew that no clinic worker would 
bring them to him, and that he would die of the same dis- 
ease that had taken his wife from him two years before. I 
searched for his name in the tuberculosis registries of 
both major hospitals in San Cristobal, but it appeared 
nowhere: no one in the health service knew he existed. 

I can only wonder about those whom I was not able to 
visit. And I can only guess at the impact of tuberculo- 
sis — particularly untreated or mistreated tuberculosis — 
on people who never even saw a doctor, on people who 
were never listed on the laboratory or treatment reg- 
istries of the district health service, on people whose 
treatment was never adequately explained or followed 
up on by health workers. 

I once asked a doctor with years of experience in war 
zones what he thought the difference was between 
humanitarian aid and human rights work. In human 
rights work, he said, your patients remain your patients 
even after they die. Your responsibility to them obviously 
changes in nature, but it does not end. Perhaps this is 
what I have learned, above all, from my summer in Chia- 
pas: to apply this statement to the conditions I saw there, 
and to understand it emotionally as well as intellectually. 

I lacked the knowledge, power, and time to make more 
than the slightest difference to most of the people I visit- 
ed. My remembering them now will not bring them back 
to health or to life. I do not absolve myself of my respon- 
sibility, however, because I do not think that morally I 
can do so. The little that I can continue to do, I will do. 
Perhaps telling their stories, little though it will bring to 
them as individuals, might at the very least make known 
their plight. ■ 

Anna Flattau '03 is a second-year student at HMS. The research 
described in this article was financed by the HMS Office of Enrich- 
ment Programs and carried out under the direction of Dr Hector 
Javier SdnchczPerczat El Colegio dc la Frontcra Sur (ECOSUR) 
in San Cristobal de las Casas, Chiapas, Mexico. Mcntorship was 
provided by Paul Farmer VO. Special thanks to Guadalupe Vargas 
for her guidance and invaluable friendship. The author may be con- 
tacted at 



The Lons Road 

Family tragedy, 
generosity, and brilliant 

entrepreneurship all 

contributed to the inside 

saga of how the Francis 

estate provided the land 

for Harvard Medical 

School and Peter Bent 

Brigham Hospital 

Longwood home traces its roots to the urJilcehest of settings: a 
battlefield. During the American Revolution, on July 7, 1777, 
Ticonderoga fell to the British. Exhausted and dispirited members 
of the Uth Massachusetts rmlitia, who had been involved in the 
action, retreated east. At dawn, the British attacked and routed 
the Americans. Mortally wounded in the fierce battle was Colonel 
Ebenezer Francis of Beverly, Massachusetts, a bricklayer and 
father of five. Before Francis was buried, a drummer boy passing 
his corpse pilfered his silver watch, then sold it to a British officer. 

to Longwood 

hy OgleSBY 


The watch was eventually returned to the widow as 
a memento of her late husband. In 1859, two of Fran- 
cis's granddaughters presented it to the Massachu- 
setts Historical Society, where it remains a cherished 
artifact of the Revolution. Yet it would fall to one of the 
young orphans Ebenezer left behind to create the most 
enduring legacy of the Francis family: the Ebenezer 
Francis estate in Roxbury, chosen at the turn of the 
twentieth century as the site of both Harvard Medical 
School and Peter Bent Brigham Hospital. 

The youngest of Colonel Francis's five children, a 
son, named Ebenezer after his father, was born in 1775 
in Beverly. He was only two years old when his father 
fell in battle. Growing up in a fatherless household 
with no breadwinner and little money, Ebenezer 
moved from Beverly to Boston and, at the age of 11, 
entered the world of work. He started out in the 

counting house of a broker who had served in the Rev- 
olutionary Army alongside his father. 

From this modest beginning, Francis launched a 
career as a dry goods merchant and eventually became 
president of a textile firm. He enjoyed considerable suc- 
cess in the world of business and finance, acting as pres- 
ident of two banks and serving as an organizing mem- 
ber of the Massachusetts Hospital Life Insurance Com- 
pany. As an outgrowth of his business activities, Francis 
also became deeply involved in Boston- area real estate. 

Laying the Groundwork 

In the early 1800s, Boston was stiU essentially an 
island, an 800-acre tract bounded by the waters of the 
Charles River and Boston Harbor, except on its south- 
west corner, where it was linked to the town of Rox- 

(Above) Taken 
in 1 878, a view 
of the Francis 
estate. (Far left) 
At the time of 
his death in 
1858, Ebenezer 
Francis >vas 
considered the 
wrealthiest man 
in New England. 



bury by a narrow strip of land appropriately called the 
"Neck." Between the southern edge of Boston at the 
Boston Common and the town of Roxbury was the 
Back Bay, a wet stretch of marsh and flats extending 
from the Charles River and the site of a frequently and 
bitterly disputed line between the two communities. 

The expansion of businesses and marine shipping, 
together with an influx of immigrants, brought not 
only prosperity, but also increasing congestion to the 
small city of Boston. The desire for space drove 
Boston's land-hungry pohticians and developers to 
aggressive tactics. They seized every opportunity to 
grab unused space and, when available plots ran out, 
they created new land by fUling in marshes and flats, 
which they then sold for a profit. 

Beginning in 1855, private investors, and then the 
commonwealth of Massachusetts, began pouring sand 
and gravel into the 100-acre watery tract that was the 
Back Bay. Lots on this new property were sold to citi- 
zens seeking homes in an area that was both fashion- 
able and less crowded than Beacon Hill. In 1859, the 
Massachusetts legislature authorized the annexation 
of these 100 acres of newly habitable land. 

In this new and shifting environment, the real estate 
affairs of Ebenezer Francis flourished. The old deed 
books of Suffolk and Norfolk counties reveal an extra- 
ordinary amount of buying, selling, and mortgaging of 
property by this one man, involving hundreds of trans- 
actions over the course of nearly six decades. In time, 
Francis's transactions came to include Roxbury and 
Brooldine, sometimes invoKing lots described merely as 
being located on an urmamed "new street." One area in 
which Francis was particularly active was Gravelly 
Point in Roxbury, a region shghtly north of the future 
Longwood medical complex. 

By 1833, Francis had bought a farm and mansion 
house in Roxbury and, because of his wealth and promi- 
nence, the access to the southern edge of his property 
was named Francis Street. Although few could have 
envisioned it at the time, this purchase, of what then was 
farmland, would represent the first crucial step in estab- 
hshing the future site of Harvard Medical School and 
Peter Bent Brigham Hospital. 

Crimson Connections 

Ebenezer Francis and his heirs would appear unlikely to 
have been involved in locating a new home for Harvard 
Medical School. Not only had Francis not attended Har- 
vard, but he had never been enrolled in any college. Yet, 
just as he had succeeded in his business affairs, Francis 
also served in important capacities in the key institu- 
tions of the Boston community. In 1817, he was elected a 

trustee of Massachusetts General Hospital, which was 
still in its planning stages. He went on to serve as chair- 
man of the trustees, as vice president, and, eventually, as 
president of the hospital in 1836. 

Francis also came to play an important role at Har- 
vard College. When the college's finances were 
plunged into disarray on the watch of a president bet- 
ter suited to scholarly pursuits than to money matters, 
Francis accepted, at no salary, the role of treasurer. He 
apphed his business acumen to restore order to the col- 
lege's financial affairs. Although his cost-tightening 
reforms may not have won him much popularity ini- 
tially, his reorganization of the college's entire financial 
structure put it on sound footing for years to come. 

Francis made other contributions to Harvard as 
well. Observing what he considered to be inferior 
table settings in the dining hall serving the students, 
he obtained the permission of the Corporation to 
order from England and personally pay for new table 
linen, cutlery, and china. He made a number of other 
gifts, including a clock for the Hbrary and contribu- 
tions toward the observatory, a burial ground in 
Mount Auburn Cemetery, and the Fund for Assisting 
Students. In recognition of these and other services, he 
received an honorary master's degree in 1843. 

A New Home for HMS 

Francis died rich — indeed, at his death in 1858 at the age 
of 82, he was considered the wealthiest man in New 
England, with a personal estate valued at the rather 
astonishing figure of nearly $3 million and real estate 
holdings worth an additional half million dollars. 

Although Francis and his wife had had seven chil- 
dren, only two had survived into adulthood. Beginning 
in I87I, Francis's heirs began a burst of purchases along 
Longwood Avenue to supplement what they already 
owned. By an 1892 accounting of the estate by the 
trustees, 33 real estate properties were hsted, including 
the Roxbury farm, 16 parcels on Longwood Avenue, and 
an additional two on Vila Street in the Longwood area. 

The transfer of the Longwood Avenue/Francis 
Street area from the Francis estate to Harvard hap- 
pened rapidly when it finally took place. In 1883, Har- 
vard Medical School had moved from North Grove 
Street to new quarters at Boylston and Exeter streets, 
both in Boston. Yet this relocation soon proved inade- 
quate for the increased number of pupils, the greater 
demands for laboratory space, and the consequences 
of a four-year rather than a three-year course of study. 

In 1895, the faculty voted to spend $100,000 in a 
futile attempt to cope with the space problem. A lead- 
ing and restless voice at Massachusetts General Hos- 

pital and Harvard Medical School was that of John 
Collins Warren, an important member of the hospital 
staff, the Moseley Professor of Surgery at Harvard, and 
the grandson of the surgeon who had, in 1846, operat- 
ed upon the first patient to receive anesthesia in a pub- 
he demonstration. In 1899, Warren approached Presi- 
dent Charles Eliot of Harvard with the possibihty of 
calling a special meeting of the faculty to seek pur- 
chase of the Francis estate, but Eliot, conscious of cost, 
rephed that he would not do so unless both the cur- 
rent dean, William Richardson, and a former dean, 
Henry Pickering Bowditch, were in favor — and 
Richardson was not. (Bowditch was not an entirely 
disinterested participant in the matter, as his aunt, 
Elizabeth Francis Bowditch, was the daughter of 
Ebenezer Francis.) 

A remarkable fellow of the Harvard Corporation 
who had been privy to the discussion about moving the 
Medical School was Major Henry Lee Higginson, a 
weU-to-do and generous Harvard alumnus and the 
civic-minded Bostonian responsible for organizing and 
financing the Boston Symphony Orchestra. Higginson 
had known Bowditch during the Civil War as a fellow 
officer in the Union Army. In 1900, Higginson wrote to 
Bowditch and Warren proposing to organize a syndi- 
cate for buying the Francis estate — the same approach 
that had been used in underwriting Boston's new 
Music HaU, shortly to be renamed Symphony Hall. 

The imaginative intervention by Higginson seems 
to have been highly effective. A memorandum of agree- 
ment was prepared, and a survey of a 26 1/2 -acre tract 

of land bounded by Francis Street on the south, Hunt- 
ington Avenue on the east, Longwood Avenue on the 
north, and Vila Street on the west was described. The 
title was transferred for approximately $600,000 from 
the trustees of the Francis estate to the syndicate, 
thanks to the bold initiative of Higginson. It was stat- 
ed in the memorandum that the president and fellows 
of Harvard College might purchase the property from 
the syndicate any time within 57 months of the agree- 
ment. Finally, there was appended a list of donors pro- 
viding collateral in the amount of $570,000. 

Through the efforts especially of John Collins War- 
ren and Henry Bowditch, Harvard was soon able to 
purchase the land from the syndicate and repay the 
collateral, having received large contributions for 
the new land and buildings from J. P. Morgan 
($1,135,000), John D. Rockefeller ($1,000,000), Mrs. 
Collis P Huntington ($250,000), and others. In 1902, 
Harvard sold at cost 10 1/2 acres of the original tract to 
the trustees of Peter Bent Brigham's estate to allow for 
the building of Peter Bent Brigham Hospital. With 
these transactions, the name "Francis estate" disap- 
peared from public and private records and memory, 
and the property was quickly transformed into a med- 
ical school and a new hospital. ■ 

Oglcshy Paul '42 is professor of medicine, emeritus at Harvard 
Medical School. The author is grateful to the Massachusetts His- 
torical Society, the New England Historic Gaiealogical Society, the 
Harvard University Archives, and the Map Department of Har- 
vard for supplying much of the information contained in this article. 

In 1906, the 
current incarna- 
tion of HMS 
was dedicated 
in a ceremony 
filled writh pomp 
and circumstance. 



i \ i ^ k J IVJ. IN u k^ X Ji \ / r I I J r^ 


Good Sports: Keeping Athletes in the Game 


and more children have 
abandoned informal games 
in their backyards in favor 
of organized sports, children's sports 
injuries have been on the rise — injuries 
such as Little League elbow, which can 
develop in young players who throw 
more than 300 overhand pitches per 
week. In the Boston area, many of these 
young athletes — in sports from soccer 
to hockey to the martial arts — end up 
seeking the help of Lyle Micheli '66, 
head of the Division of Sports Medicine 
at Children's Hospital and associate 
clinical professor of orthopedic surgery 
at HMS. 

Established in 1974, the Division of 
Sports Medicine was the first children's 
sports medicine clinic in the country. 

Only a handful of similar clinics exist 
worldwide, and most of the physicians 
staffing those clinics are former fellows 
of Micheli, who has devoted his career 
to promoting both general physical 
activity for everyone and safety for 
those involved in the intense training of 
organized athletics. 

Micheli notes that when the clinic 
opened, he treated mainly traumatic 
injuries; today, most are overuse 
injuries from excessive training. Chil- 
dren are especially prone to overuse 
injuries because their bones are still 
growing — Micheli often sees patients 
as young as six. "We want kids to be 
physically active for health, weight 
control, and psychological develop- 
ment," he says, "but we're still strug- 
gling to find the best formula. In fact. 

PLAYING IT SAFE: Through education and treatment, Lyle Micheli helps young 
athletes enjoy a long and healthy relationship v\^ith sports. 

the best formula may be a lot of general 
physical activity and then short doses of 
organized sports." 

But the emphasis on organized 
sports for children is a trend that 
Micheli says is here to stay. His goal is 
to make participation in these activi- 
ties as enjoyable and safe as possible. 
"One of the disappointments of sports 
medicine is that when a new activity 
becomes popular, we go through the 
same cycle of unnecessary injuries and 
people needing to be educated," 
he explains. Micheh beheves that this 
pattern could be significantly 
changed by the imple- 
mentation of one 
relati^'ely simple pro- 
gram: coaching certifi- 
cation. Currently, volunteers who coach 
young children require none. 

"If you want to go out and become 
a soccer coach tomorrow, you can," 
Micheli says. "You may know nothing 
about soccer, fitness, stretching, or 
strengthening, but you'll be a soccer 
coach. I'm not against volunteerism, but 
there has to be some kind of training." 

To that end, MicheU and his team, 
with the American Red Cross and the 
U.S. Olympic Association, helped devel- 
op a training program for coaches. It's 
only a 16-hour, weekend course, but in 
that short time, Micheh says, you can 
impart a great deal of vital information 
that will help prevent injuries and allow 
them to be dealt wdth eEectively when 
they do occur. Coaches need to learn the 
risk areas for their sport, the basics of 
first aid, and how to be responsive to 
ctuldreris complaints. They also need to 
perceive themselves as being responsible 
for the health of their young charges. 

Micheli aims to make a strong con- 
nection between sports and health care. 
His group recently received a grant from 
the Robert Wood Johnson Foundation 
to estabhsh youth sports programs to be 
based at two community health centers 
in Mattapan, Massachusetts. Working 



with the Center 
for Sports and Society at North- 
eastern University and the Harvard 
School of Pubhc Health, Micheli hopes 
the program will encourage coaches to 
think of themselves as part of a public 
health intervention. 

In Micheli's own life, sports and 
physical activity have always been 
important elements. A former football 
and rugby player, he currently serves on 
the U.S. Rugby Board, working to pro- 
mote safety in rugby. "It's a good game," 
Micheli says, "when properly played." 
He recently took part in a reunion rugby 
game. These days he enjoys cycling and 
fishing; he walks everywhere, including 
to work, and goes to the gym every day 
of the week. He's also the proud father 
of two physically active daughters; 
the younger is a member of the U.S. 
women's rugby team; the elder, an envi- 
ronmental scientist, participates in 
rowing. He is pleased that his daughters 
have taken to heart the importance of 
incorporating physical activity into 
one's daily life for optimal health. 

Dramatic Finishes 

One popular activity that may not be 
all that helpful in maintaining general 
health, however, is marathon running. 
"Marathoning is a very special athletic 
event," Micheli says. "You're not doing 
it for fitness." He cites a prominent 

local running coach who says he can 
make practically anyone able to run a 
marathon, if that person is willing to 
devote enough time to training. Unfor- 
tunately, some people don't devote 
enough time to training, and that's 
where Micheli comes in. He has been at 
the finish line of the Boston Marathon 
every year since 1975. Back then, about 
900 runners ran the race, and there 
were eight people on the medical team. 
Now, with 10,000 to 13,000 runners, the 
medical team numbers more than a 
hundred doctors, nurses, physical ther- 
apists, and athletic trainers. 

Micheli and his team generally treat 
anywhere from 3 to 5 percent of those 
runners, and in the course of the day 
start more than 150 IVs. One particular- 
ly dramatic finish that Micheli wit- 
nessed was that of a man who fell down 
about five yards short of the finish line, 
got back up, and staggered across to fall 
again. "We pulled him under the barri- 
er and saw that his painful leg was 
about four inches shorter than the 
other," Micheli recalls. "He had sus- 
tained a stress fracture during the 
course of the race, which broke through 
five yards from the finish line. He ran 
the final five yards on a broken and dis- 
placed femur!" 

Athleticism and drama also meet in 
another of Micheli's roles, as a consul- 
tant to the Boston Ballet. By applying to 
dancers the tools they have developed 
with athletes, Micheli and his team 

have been successful in helping to pre- 
vent dancers' injuries. Today there are 
therapists at the Boston Ballet every 
day, the first line of defense for dancers 
who are just beginning to develop prob- 
lems. In addition, each dancer's physi- 
cal condition is assessed at the begin- 
ning and end of each season, a practice 
that had never existed before. 

Despite his extensive knowledge of 
the dancers' conditions, however, 
Micheli is careful to maintain confiden- 
tiality; he doesn't communicate with the 
company administration about their 
injuries. The dancers are comfortable 
reporting injuries and getting problems 
looked at sooner rather than later. "It's 
been a two-way street," Micheli says of 
his successful collaboration with the 
ballet. "The dancers have educated me, 
and I hope I've educated them." 

Such collaborations often yield rich 
rewards. On a wall in Micheli's office is 
a framed photograph of a ballet dancer 
in glorious mid-leap. When she came 
down from that leap, Micheli explains, 
she tore her Achilles tendon, a poten- 
tially career-ending injury. With 
Micheli's help and intensive rehabilita- 
tion, she recovered from her injury and 
resumed dancing five months later. In 
the corner of the photo is the dancer's 
inscription, thanking Micheli for saving 
her career. ■ 

Susan Cassidy is assistant editor of the 
Harvard Medical Alumni Bulletin. 



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